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Abdelmalek CM, Singh S, Fasil B, Horvath AR, Mulkey SB, Curé C, Campos M, Cavalcanti DP, Tong VT, Mercado M, Daza M, Marcela Benavides M, Acosta J, Gilboa S, Valencia D, Sancken CL, Newton S, Scalabrin DMF, Mussi-Pinhata MM, Vasconcelos Z, Chakhtoura N, Moye J, Leslie EJ, Bulas D, Vezina G, Marques FJP, Leyser M, Del Campo M, Vilain E, DeBiasi RL, Wang T, Nath A, Haydar T, Muenke M, Mansour TA, du Plessis AJ, Murray JC, Cordero JF, Kousa YA. Building a growing genomic data repository for maternal and fetal health through the PING Consortium. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.24.24307899. [PMID: 38826415 PMCID: PMC11142296 DOI: 10.1101/2024.05.24.24307899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Background Prenatally transmitted viruses can cause severe damage to the developing brain. There is unexplained variability in prenatal brain injury and postnatal neurodevelopmental outcomes, suggesting disease modifiers. Discordant outcomes among dizygotic twins could be explained by genetic susceptibly or protection. Among several well-recognized threats to the developing brain, Zika is a mosquito-borne, positive-stranded RNA virus that was originally isolated in Uganda and spread to cause epidemics in Africa, Asia, and the Americas. In the Americas, the virus caused congenital Zika syndrome and a multitude of neurodevelopmental disorders. As of now, there is no preventative treatment or cure for the adverse outcomes caused by prenatal Zika infection. The Prenatal Infection and Neurodevelopmental Genetics (PING) Consortium was initiated in 2016 to identify factors modulating prenatal brain injury and postnatal neurodevelopmental outcomes for Zika and other prenatal viral infections. Methods The Consortium has pooled information from eight multi-site studies conducted at 23 research centers in six countries to build a growing clinical and genomic data repository. This repository is being mined to search for modifiers of virally induced brain injury and developmental outcomes. Multilateral partnerships include commitments with Children's National Hospital (USA), Instituto Nacional de Salud (Colombia), the Natural History of Zika Virus Infection in Gestation program (Brazil), and Zika Instituto Fernandes Figueira (Brazil), in addition to the Centers for Disease Control and Prevention and the National Institutes of Health. Discussion Our goal in bringing together these sets of patient data was to test the hypothesis that personal and populational genetic differences affect the severity of brain injury after a prenatal viral infection and modify neurodevelopmental outcomes. We have enrolled 4,102 mothers and 3,877 infants with 3,063 biological samples and clinical data covering over 80 phenotypic fields and 5,000 variables. There were several notable challenges in bringing together cohorts enrolled in different studies, including variability in the timepoints evaluated and the collected clinical data and biospecimens. Thus far, we have performed whole exome sequencing on 1,226 participants. Here, we present the Consortium's formation and the overarching study design. We began our investigation with prenatal Zika infection with the goal of applying this knowledge to other prenatal infections and exposures that can affect brain development.
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Wongsawat J, Thamthitiwat S, Hicks VJ, Uttayamakul S, Teepruksa P, Sawatwong P, Skaggs B, Mock PA, MacArthur JR, Suya I, Sapchookul P, Kitsutani P, Lo TQ, Vachiraphan A, Kovavisarach E, Rhee C, Darun P, Saepueng K, Waisaen C, Jampan D, Sriboonrat P, Palanuwong B, Sukbut P, Areechokchai D, Pittayawonganon C, Iamsirithaworn S, Bloss E, Rao CY. Characteristics, risk factors, and outcomes related to Zika virus infection during pregnancy in Northeastern Thailand: A prospective pregnancy cohort study, 2018-2020. PLoS Negl Trop Dis 2024; 18:e0012176. [PMID: 38758964 PMCID: PMC11139345 DOI: 10.1371/journal.pntd.0012176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 05/30/2024] [Accepted: 04/29/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND In response to the 2015-2016 Zika virus (ZIKV) outbreak and the causal relationship established between maternal ZIKV infection and adverse infant outcomes, we conducted a cohort study to estimate the incidence of ZIKV infection in pregnancy and assess its impacts in women and infants. METHODOLOGY/PRINCIPAL FINDINGS From May 2018-January 2020, we prospectively followed pregnant women recruited from 134 participating hospitals in two non-adjacent provinces in northeastern Thailand. We collected demographic, clinical, and epidemiologic data and blood and urine at routine antenatal care visits until delivery. ZIKV infections were confirmed by real-time reverse transcriptase polymerase chain reaction (rRT-PCR). Specimens with confirmed ZIKV underwent whole genome sequencing. Among 3,312 women enrolled, 12 (0.36%) had ZIKV infections, of which two (17%) were detected at enrollment. Ten (83%, 3 in 2nd and 7 in 3rd trimester) ZIKV infections were detected during study follow-up, resulting in an infection rate of 0.15 per 1,000 person-weeks (95% CI: 0.07-0.28). The majority (11/12, 91.7%) of infections occurred in one province. Persistent ZIKV viremia (42 days) was found in only one woman. Six women with confirmed ZIKV infections were asymptomatic until delivery. Sequencing of 8 ZIKV isolates revealed all were of Asian lineage. All 12 ZIKV infected women gave birth to live, full-term infants; the only observed adverse birth outcome was low birth weight in one (8%) infant. Pregnancies in 3,300 ZIKV-rRT-PCR-negative women were complicated by 101 (3%) fetal deaths, of which 67 (66%) had miscarriages and 34 (34%) had stillbirths. There were no differences between adverse fetal or birth outcomes of live infants born to ZIKV-rRT-PCR-positive mothers compared to live infants born to ZIKV-rRT-PCR-negative mothers. CONCLUSIONS/SIGNIFICANCE Confirmed ZIKV infections occurred infrequently in this large pregnancy cohort and observed adverse maternal and birth outcomes did not differ between mothers with and without confirmed infections.
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Affiliation(s)
- Jurai Wongsawat
- Thailand Ministry of Public Health, Department of Disease Control, Nonthaburi, Thailand
| | - Somsak Thamthitiwat
- Thailand Ministry of Public Health–US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Victoria J. Hicks
- US Centers for Disease Control and Prevention, Division of Global Health Protection, Atlanta, Georgia, United States of America
| | - Sumonmal Uttayamakul
- Thailand Ministry of Public Health, Department of Disease Control, Nonthaburi, Thailand
| | - Phanthaneeya Teepruksa
- Thailand Ministry of Public Health–US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Pongpun Sawatwong
- Thailand Ministry of Public Health–US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Beth Skaggs
- Thailand Ministry of Public Health–US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
- US Centers for Disease Control and Prevention, Division of Global Health Protection, Atlanta, Georgia, United States of America
| | - Philip A. Mock
- Thailand Ministry of Public Health–US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - John R. MacArthur
- Thailand Ministry of Public Health–US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
- US Centers for Disease Control and Prevention, Division of Global Health Protection, Atlanta, Georgia, United States of America
| | - Inthira Suya
- Thailand Ministry of Public Health–US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Patranuch Sapchookul
- Thailand Ministry of Public Health–US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Paul Kitsutani
- Thailand Ministry of Public Health–US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
- US Centers for Disease Control and Prevention, Division of Global Health Protection, Atlanta, Georgia, United States of America
| | - Terrence Q. Lo
- US Centers for Disease Control and Prevention, Division of Global Health Protection, Atlanta, Georgia, United States of America
| | - Apichart Vachiraphan
- Thailand Ministry of Public Health, Department of Disease Control, Nonthaburi, Thailand
| | - Ekachai Kovavisarach
- Thailand Ministry of Public Health, Department of Medical Services, Nonthaburi, Thailand
| | - Chulwoo Rhee
- US Centers for Disease Control and Prevention, Division of Global Health Protection, Atlanta, Georgia, United States of America
| | - Pamorn Darun
- Bueng Kan Provincial Public Health Office, Bueng Kan, Thailand
| | | | - Chamnan Waisaen
- Bueng Kan Provincial Public Health Office, Bueng Kan, Thailand
| | | | | | | | | | - Darin Areechokchai
- Thailand Ministry of Public Health, Department of Disease Control, Nonthaburi, Thailand
| | | | - Sopon Iamsirithaworn
- Thailand Ministry of Public Health, Department of Disease Control, Nonthaburi, Thailand
| | - Emily Bloss
- Thailand Ministry of Public Health–US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
- US Centers for Disease Control and Prevention, Division of Global Health Protection, Atlanta, Georgia, United States of America
| | - Carol Y. Rao
- Thailand Ministry of Public Health–US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
- US Centers for Disease Control and Prevention, Division of Global Health Protection, Atlanta, Georgia, United States of America
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Balea R, Pollak NM, Hobson-Peters J, Macdonald J, McMillan DJ. Development and pre-clinical evaluation of a Zika virus diagnostic for low resource settings. Front Microbiol 2023; 14:1214148. [PMID: 38053551 PMCID: PMC10694267 DOI: 10.3389/fmicb.2023.1214148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 11/06/2023] [Indexed: 12/07/2023] Open
Abstract
Introduction Zika virus (ZIKV) is a re-emerging flavivirus that poses a significant public health threat. ZIKV exhibits a wide array of non-vector borne human transmission routes, such as sexual transmission, transplacental transmission and blood transfusion. Detection and surveillance of ZIKV is considered paramount in prevention of major outbreaks. With the majority of cases reported in low-resource locations, simple, low-cost detection methods are considered highly desirable. Materials and Methods Here we have developed a sensitive and specific ZIKV diagnostic using reverse transcription recombinase-aided amplification (RT-RAA) coupled with lateral flow detection (LFD) targeting a highly conserved region of the ZIKV NS1 gene. Results We show our rapid, isothermal-ZIKV-diagnostic (Iso-ZIKV-Dx) can detect 500 copies of synthetic ZIKV RNA/μL in under 30 min at a constant 39°C. Using simulated urine samples, we observed that Iso-ZIKV-Dx also detects as low as 34.28 RNA copies/reaction of ZIKV (MR766 strain). Specificity testing confirmed that our test does not detect any co-circulating flaviviruses (dengue, West Nile, Japanese encephalitis, Murray Valley encephalitis and yellow fever viruses) or chikungunya virus. Sample processing results show complete inactivation of ZIKV (MR766 strain) in 5 min at room temperature using our novel viral RNA sample preparation reagent. Furthermore, lateral flow strips testing demonstrates positive diagnoses in as little as 5 min in running buffer. Discussion Contrary to conventional RT-qPCR, our Iso-ZIKV-Dx does not require expensive machinery, specialised laboratory settings or extensively trained personnel. Pre-clinical evaluation demonstrates that our test exhibits robust, in-field capabilities without compromising sensitivity or specificity. When compared to the gold-standard RT-qPCR, our Iso-ZIKV-Dx test offers an array of applications that extend beyond diagnostics alone, including potential for surveillance and monitoring of ZIKV vector competency.
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Affiliation(s)
- Rickyle Balea
- Centre for Bioinnovation, University of the Sunshine Coast, Sippy Downs, QLD, Australia
- School of Science, Technology and Engineering, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Nina M. Pollak
- Centre for Bioinnovation, University of the Sunshine Coast, Sippy Downs, QLD, Australia
- School of Science, Technology and Engineering, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Jody Hobson-Peters
- School of Chemistry and Molecular Biosciences, The University of Queensland, St Lucia, QLD, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, St Lucia, QLD, Australia
| | - Joanne Macdonald
- School of Science, Technology and Engineering, University of the Sunshine Coast, Sippy Downs, QLD, Australia
- BioCifer Pty Ltd., Auchenflower, QLD, Australia
| | - David J. McMillan
- Centre for Bioinnovation, University of the Sunshine Coast, Sippy Downs, QLD, Australia
- School of Science, Technology and Engineering, University of the Sunshine Coast, Sippy Downs, QLD, Australia
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Fialho EMS, Veras EM, Jesus CMD, Gomes LN, Khouri R, Sousa PS, Ribeiro MRC, Batista RFL, Costa LC, Nascimento FRF, Silva AAM, Soeiro-Pereira PV. Maternal Th17 Profile after Zika Virus Infection Is Involved in Congenital Zika Syndrome Development in Children. Viruses 2023; 15:1320. [PMID: 37376620 DOI: 10.3390/v15061320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 05/31/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023] Open
Abstract
Brazil is one of the countries that experienced an epidemic of microcephaly and other congenital manifestations related to maternal Zika virus infection which can result in Congenital Zika Syndrome (CZS). Since the Zika virus can modulate the immune system, studying mothers' and children's immune profiles become essential to better understanding CZS development. Therefore, we investigated the lymphocyte population profile of children who developed CZS and their mothers' immune response in this study. The study groups were formed from the Plaque Reduction Neutralization Test (PRNT) (CZS+ group) result. To evaluate the lymphocyte population profile, we performed phenotyping of peripheral lymphocytes and quantification of serum cytokine levels. The immunophenotyping and cytokine profile was correlated between CSZ+ children and their mothers. Both groups exhibited increased interleukin-17 levels and a reduction in the subpopulation of CD4+ T lymphocytes. In contrast, the maternal group showed a reduction in the population of B lymphocytes. Thus, the development of CZS is related to the presence of an inflammatory immune profile in children and their mothers characterized by Th17 activation.
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Affiliation(s)
- Eder M S Fialho
- Health Sciences Graduate Program, Biological and Health Sciences Center, Federal University of Maranhão, São Luís 65080-805, MA, Brazil
| | - Emanoel M Veras
- Medical School, Federal University of Maranhão, São Luís 65080-805, MA, Brazil
| | - Caroline M de Jesus
- Health and Technology Graduate Program, Biological and Health Sciences Center, Federal University of Maranhão, São Luís 65080-805, MA, Brazil
| | - Líllian N Gomes
- Department of Immunology, University of São Paulo, São Paulo 05508-000, SP, Brazil
| | - Ricardo Khouri
- Gonçalo Moniz Research Institute, FIOCRUZ-Bahia, Salvador 40296-710, BA, Brazil
| | - Patrícia S Sousa
- Reference Center on Neurodevelopment, Assistance and Rehabilitation of Children/NINAR-State Department of Health of the State of Maranhão, São Luís 65077-357, MA, Brazil
| | - Marizélia R C Ribeiro
- Department of Medicine III, Federal University of Maranhão, São Luís 65020-240, MA, Brazil
| | - Rosângela F L Batista
- Department of Public Health, Federal University of Maranhão, São Luís 65020-060, MA, Brazil
| | - Luciana C Costa
- Department of Public Health, Federal University of Maranhão, São Luís 65020-060, MA, Brazil
| | - Flávia R F Nascimento
- Health Sciences Graduate Program, Biological and Health Sciences Center, Federal University of Maranhão, São Luís 65080-805, MA, Brazil
- Department of Pathology, Federal University of Maranhão, São Luís 65065-545, MA, Brazil
| | - Antônio A M Silva
- Department of Public Health, Federal University of Maranhão, São Luís 65020-060, MA, Brazil
| | - Paulo V Soeiro-Pereira
- Health Sciences Graduate Program, Biological and Health Sciences Center, Federal University of Maranhão, São Luís 65080-805, MA, Brazil
- Department of Pathology, Federal University of Maranhão, São Luís 65065-545, MA, Brazil
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Villalobos-Sánchez E, Burciaga-Flores M, Zapata-Cuellar L, Camacho-Villegas TA, Elizondo-Quiroga DE. Possible Routes for Zika Virus Vertical Transmission in Human Placenta: A Comprehensive Review. Viral Immunol 2022; 35:392-403. [PMID: 35506896 DOI: 10.1089/vim.2021.0199] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Zika virus (ZIKV) infections have gained notoriety due to congenital abnormalities. Pregnant women have a greater risk of ZIKV infection and consequent transmission to their progeny due to the immunological changes associated with pregnancy. ZIKV has been detected in amniotic fluid, as well as in fetal and neonatal tissues of infected pregnant women. However, the mechanism by which ZIKV reaches the fetus is not well understood. The four dengue virus serotypes have been the most widely used flaviviruses to elucidate the host-cell entry pathways. Nevertheless, it is of increasing interest to understand the specific interaction between ZIKV and the host cell, especially in the gestation period. Herein, the authors describe the mechanisms of prenatal vertical infection of ZIKV based on results from in vitro, in vivo, and ex vivo studies, including murine models and nonhuman primates. It also includes up-to-date knowledge from ex vivo and natural infections in pregnant women explaining the vertical transmission along four tracks: transplacental, paracellular, transcytosis mediated by extracellular vesicles, and paraplacental route and the antibody-dependent enhancement process. A global understanding of the diverse pathways used by ZIKV to cross the placental barrier and access the fetus, along with a better comprehension of the pathogenesis of ZIKV in pregnant females, may constitute a fundamental role in the design of antiviral drugs to reduce congenital disabilities associated with ZIKV.
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Affiliation(s)
- Erendira Villalobos-Sánchez
- Medical and Pharmaceutical Biotechnology Unit, Center for Research and Assistance in Technology and Design of the State of Jalisco (CIATEJ), Guadalajara, México
| | - Mirna Burciaga-Flores
- Medical and Pharmaceutical Biotechnology Unit, Center for Research and Assistance in Technology and Design of the State of Jalisco (CIATEJ), Guadalajara, México
| | - Lorena Zapata-Cuellar
- Medical and Pharmaceutical Biotechnology Unit, Center for Research and Assistance in Technology and Design of the State of Jalisco (CIATEJ), Guadalajara, México
| | - Tanya A Camacho-Villegas
- CONACYT-Medical and Pharmaceutical Biotechnology Unit, Center for Research and Assistance in Technology and Design of the State of Jalisco (CIATEJ), Guadalajara, México
| | - Darwin E Elizondo-Quiroga
- Medical and Pharmaceutical Biotechnology Unit, Center for Research and Assistance in Technology and Design of the State of Jalisco (CIATEJ), Guadalajara, México
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Gutiérrez-Sánchez LÁ, Becerra-Mojica CH, Rojas MA, Díaz-Martínez LA, Pérez Vera LA, Contreras García GA, Pinilla García LS. Fetal central nervous system anomalies according to RT-PCR and trimester of maternal infection with Zika virus: A prospective cohort study. Acta Obstet Gynecol Scand 2021; 101:221-231. [PMID: 34904224 DOI: 10.1111/aogs.14301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION In October 2015, an epidemic of Zika began in Colombia's geographic areas with a high population of mosquitoes of the genus Aedes. We aimed to describe the fetal brain ultrasound findings in pregnant women with active symptoms or a history of symptoms suggestive of Zika virus (ZIKV) infection. MATERIAL AND METHODS Eligible pregnant women were tested with reverse transcriptase-polymerase chain reaction (RT-PCR) for ZIKV and followed prospectively using detailed anatomic ultrasound and transvaginal neurosonography to detect structural anomalies of the fetal central nervous system (CNS). RESULTS A total of 115 symptomatic women with a positive ZIKV RT-PCR and 55 with a negative ZIKV RT-PCR were enrolled in the study; CNS compromise of the fetus occurred in 22% and 17%, respectively (p = 0.255). Callosal dysgenesis (14.5%) was the most frequent anomaly of the CNS, followed by microcephaly (13.6%) and neuronal migration disorders (8.3%). When symptomatic ZIKV RT-PCR-positive women were categorized by trimester of infection, CNS anomalies were present in 40% of first-trimester infections, compared with 21% and 7% in second- and third-trimester infections (p = 0.002). CNS anomalies were also more severe in first-trimester-infected fetuses than in second- and third-trimester-infected fetuses. The high prevalence of CNS anomalies in fetuses of symptomatic ZIKV RT-PCR negative women suggests a high rate of false-negative cases and an even higher prevalence of CNS anomalies than observed in this study. CONCLUSIONS The prevalence of fetal CNS anomalies was higher than previously reported in the literature for both symptomatic RT-PCR-positive and -negative pregnant women. Corpus callosum anomalies, microcephaly, neuronal migration disorders, and brain parenchymal hyperechogenicities were the most frequent CNS anomalies detected. In addition, CNS anomalies were more frequent and severe in infected fetuses during the first trimester of pregnancy than during the second or third trimester.
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Affiliation(s)
- Luz Ángela Gutiérrez-Sánchez
- School of Medicine, Health Faculty, Universidad Industrial de Santander, Bucaramanga, Colombia.,Maternal-Fetal Medicine Unit, Hospital Universitario de Santander, Bucaramanga, Colombia.,Clínica Materno Infantil San Luis, Bucaramanga, Colombia
| | - Carlos Hernán Becerra-Mojica
- School of Medicine, Health Faculty, Universidad Industrial de Santander, Bucaramanga, Colombia.,Maternal-Fetal Medicine Unit, Hospital Universitario de Santander, Bucaramanga, Colombia.,Fundación Oftalmológica de Santander, Clínica Carlos Ardila Lülle, Bucaramanga, Colombia
| | - Mario Augusto Rojas
- School of Medicine, Health Faculty, Universidad Industrial de Santander, Bucaramanga, Colombia.,Colombian Association of Neonatology, Colombian Neonatal Research Network, Bogotá, Colombia
| | - Luis Alfonso Díaz-Martínez
- School of Medicine, Health Faculty, Universidad Industrial de Santander, Bucaramanga, Colombia.,Neonatal Unit, Hospital Universitario de Santander, Bucaramanga, Colombia
| | - Luis Alfonso Pérez Vera
- School of Medicine, Health Faculty, Universidad Industrial de Santander, Bucaramanga, Colombia.,Colombian Association of Neonatology, Colombian Neonatal Research Network, Bogotá, Colombia
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Ruiz-Burga E, Bruijning-Verhagen P, Palmer P, Sandcroft A, Fernandes G, de Hoog M, Bryan L, Pierre R, Bailey H, Giaquinto C, Thorne C, Christie CDC. The ZIKApp for detection of potential arbovirus infections and pregnancy complications in pregnant women in Jamaica: a pilot study (Preprint). JMIR Form Res 2021; 6:e34423. [PMID: 35896029 PMCID: PMC9377438 DOI: 10.2196/34423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 02/23/2022] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Elisa Ruiz-Burga
- Population, Policy & Practice Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Patricia Bruijning-Verhagen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Paulette Palmer
- Department of Child and Adolescent Health, University of the West Indies, Kingston, Jamaica
| | - Annalisa Sandcroft
- Department of Child and Adolescent Health, University of the West Indies, Kingston, Jamaica
| | - Georgina Fernandes
- Population, Policy & Practice Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Marieke de Hoog
- University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Lenroy Bryan
- Department of Obstetrics and Gynaecology, University of the West Indies, Kingston, Jamaica
| | - Russell Pierre
- Department of Child and Adolescent Health, University of the West Indies, Kingston, Jamaica
| | - Heather Bailey
- Institute for Global Health, University College London, London, United Kingdom
| | - Carlo Giaquinto
- Dipartimento di Salute della Donna e del Bambino, Università degli Studi di Padova, Padova, Italy
| | - Claire Thorne
- Population, Policy & Practice Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Celia D C Christie
- Department of Child and Adolescent Health, University of the West Indies, Kingston, Jamaica
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8
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Phatihattakorn C, Wongsa A, Pongpan K, Anuwuthinawin S, Mungmanthong S, Wongprasert M, Tassaneetrithep B. Seroprevalence of Zika virus in pregnant women from central Thailand. PLoS One 2021; 16:e0257205. [PMID: 34516583 PMCID: PMC8437263 DOI: 10.1371/journal.pone.0257205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 08/25/2021] [Indexed: 11/23/2022] Open
Abstract
Zika virus (ZKV) infection in a pregnant woman, especially during the first trimester, often results in congenital anomalies. However, the pathogenic mechanism is unknown and one-third of ZKV infected pregnancies are asymptomatic. Neutralizing antibodies against ZKV has been reported in 70% of Thai adults, but the prevalence among pregnant women is unknown. Currently, vaccines and specific treatments for ZKV are under development. A better understanding of the immune status of pregnant women will increase the success of effective prevention guidelines. The prevalence of ZKV infection in pregnant women in antenatal care clinics was investigated during the rainy season from May to October 2019 at Siriraj Hospital, Bangkok, Thailand. We recruited 650 pregnant women (39.42% first, 52.26% second and 7.36% third trimester) and found that 30.77% had ZKV-specific IgG, and 39.81% had neutralizing antibodies (nAb) against ZKV (titer ≥10). Specific and neutralizing antibody levels varied by maternal age, trimester, and month. We further characterized the cross-reaction between ZKV and the four Dengue virus (DENV) serotypes by focused reduction neutralization test (FRNT) and found that cross-reactions were common. In conclusion, about 60% of pregnant women who living in central Thailand may be at risk of ZKV infection due to the absence of neutralizing antibodies against ZKV. The functions of cross-reactive antibodies between related viral genotypes require further study. These findings have implications for health care monitoring in pregnant women including determining the risk of ZKV infection, assisting the development of a flavivirus vaccine, and informing the development of preventative health policies.
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Affiliation(s)
- Chayawat Phatihattakorn
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Center of Research Excellence in Immunoregulation, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Artit Wongsa
- Center of Research Excellence in Immunoregulation, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kirakorn Pongpan
- Center of Research Excellence in Immunoregulation, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sanitra Anuwuthinawin
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sakita Mungmanthong
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Manthana Wongprasert
- Division of Obstetrics and Gynecology Nursing, Department of Nursing, Siriraj Hospital, Bangkok, Thailand
| | - Boonrat Tassaneetrithep
- Center of Research Excellence in Immunoregulation, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- * E-mail:
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9
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Westrich JA, McNulty EE, Edmonds MJ, Nalls AV, Miller MR, Foy BD, Rovnak J, Perera R, Mathiason CK. Characterization of subclinical ZIKV infection in immune-competent guinea pigs and mice. J Gen Virol 2021; 102. [PMID: 34410903 PMCID: PMC8513637 DOI: 10.1099/jgv.0.001641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
An infectious agent’s pathogenic and transmission potential is heavily influenced by early events during the asymptomatic or subclinical phase of disease. During this phase, the presence of infectious agent may be relatively low. An important example of this is Zika virus (ZIKV), which can cross the placenta and infect the foetus, even in mothers with subclinical infections. These subclinical infections represent roughly 80 % of all human infections. Initial ZIKV pathogenesis studies were performed in type I interferon receptor (IFNAR) knockout mice. Blunting the interferon response resulted in robust infectivity, and increased the utility of mice to model ZIKV infections. However, due to the removal of the interferon response, the use of these models impedes full characterization of immune responses to ZIKV-related pathologies. Moreover, IFNAR-deficient models represent severe disease whereas less is known regarding subclinical infections. Investigation of the anti-viral immune response elicited at the maternal-foetal interface is critical to fully understand mechanisms involved in foetal infection, foetal development, and disease processes recognized to occur during subclinical maternal infections. Thus, immunocompetent experimental models that recapitulate natural infections are needed. We have established subclinical intravaginal ZIKV infections in mice and guinea pigs. We found that these infections resulted in: the presence of both ZIKV RNA transcripts and infectious virus in maternal and placental tissues, establishment of foetal infections and ZIKV-mediated CXCL10 expression. These models will aid in discerning the mechanisms of subclinical ZIKV mother-to-offspring transmission, and by extension can be used to investigate other maternal infections that impact foetal development.
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Affiliation(s)
- Joseph A Westrich
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Erin E McNulty
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Marisa J Edmonds
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Amy V Nalls
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Megan R Miller
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Brian D Foy
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Joel Rovnak
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Rushika Perera
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Candace K Mathiason
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
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10
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Qiao L, Martelli CMT, Raja AI, Sanchez Clemente N, de Araùjo TVB, Ximenes RADA, Miranda-Filho DDB, Ramond A, Brickley EB. Epidemic preparedness: Prenatal Zika virus screening during the next epidemic. BMJ Glob Health 2021; 6:bmjgh-2021-005332. [PMID: 34117012 PMCID: PMC8202108 DOI: 10.1136/bmjgh-2021-005332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/10/2021] [Indexed: 12/29/2022] Open
Abstract
Zika virus (ZIKV) is a vectorborne infectious agent of global public health significance due to its potential to cause severe teratogenic outcomes. The question of whether health systems should consider adopting screening programmes for ZIKV infections during pregnancy warrants consideration. In this analysis, we apply the Wilson-Jungner framework to appraise the potential utility of a prenatal ZIKV screening programme, outline potential screening strategies within the case-finding pathway, and consider other epidemiological factors that may influence the planning of such a screening programme. Our evaluation of a potential prenatal ZIKV screening programme highlights factors affirming its usefulness, including the importance of Congenital Zika Syndrome as a public health problem and the existence of analogous congenital prenatal screening programmes for STORCH agents (syphilis, toxoplasmosis, others (eg, human immunodeficiency virus, varicella-zoster virus, parvovirus B19), rubella, cytomegalovirus, and herpes simplex virus). However, our assessment also reveals key barriers to implementation, such as the need for more accurate diagnostic tests, effective antiviral treatments, increased social service capacity, and surveillance. Given that the reemergence of ZIKV is likely, we provide a guiding framework for policymakers and public health leaders that can be further elaborated and adapted to different contexts in order to reduce the burden of adverse ZIKV-related birth outcomes during future outbreaks.
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Affiliation(s)
- Luxi Qiao
- Health Equity Action Lab, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.,School of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | | | - Amber I Raja
- Health Equity Action Lab, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Nuria Sanchez Clemente
- Health Equity Action Lab, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Ricardo Arraes de Alencar Ximenes
- Departamento de Medicina Tropical, Universidade Federal de Pernambuco, Recife, Pernambuco, Brasil.,Departamento de Medicina Interna, Universidade de Pernambuco, Recife, Pernambuco, Brasil
| | | | - Anna Ramond
- Health Equity Action Lab, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth B Brickley
- Health Equity Action Lab, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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11
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Kousa YA, Hossain RA. Causes of Phenotypic Variability and Disabilities after Prenatal Viral Infections. Trop Med Infect Dis 2021; 6:tropicalmed6020095. [PMID: 34205913 PMCID: PMC8293342 DOI: 10.3390/tropicalmed6020095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 05/25/2021] [Accepted: 05/29/2021] [Indexed: 12/14/2022] Open
Abstract
Prenatal viral infection can lead to a spectrum of neurodevelopmental disabilities or fetal demise. These can include microencephaly, global developmental delay, intellectual disability, refractory epilepsy, deafness, retinal defects, and cortical-visual impairment. Each of these clinical conditions can occur on a semi-quantitative to continuous spectrum, from mild to severe disease, and often as a collective of phenotypes. Such serious outcomes result from viruses’ overlapping neuropathology and hosts’ common neuronal and gene regulatory response to infections. The etiology of variability in clinical outcomes is not yet clear, but it may be related to viral, host, vector, and/or environmental risk and protective factors that likely interact in multiple ways. In this perspective of the literature, we work toward understanding the causes of phenotypic variability after prenatal viral infections by highlighting key aspects of the viral lifecycle that can affect human disease, with special attention to the 2015 Zika pandemic. Therefore, this work offers important insights into how viral infections and environmental teratogens affect the prenatal brain, toward our ultimate goal of preventing neurodevelopmental disabilities.
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Affiliation(s)
- Youssef A. Kousa
- Division of Neurology, Children’s National Hospital, Washington, DC 20010, USA
- Department of Genomics and Precision Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC 20052, USA
- Correspondence:
| | - Reafa A. Hossain
- Structural Virology Section, Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institute of Health, Bethesda, MD 20892, USA;
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12
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Zika-related adverse outcomes in a cohort of pregnant women with rash in Pernambuco, Brazil. PLoS Negl Trop Dis 2021; 15:e0009216. [PMID: 33684110 PMCID: PMC7971861 DOI: 10.1371/journal.pntd.0009216] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 03/18/2021] [Accepted: 02/07/2021] [Indexed: 11/20/2022] Open
Abstract
Background While Zika virus (ZIKV) is now widely recognized as a teratogen, the frequency and full spectrum of adverse outcomes of congenital ZIKV infection remains incompletely understood. Methods Participants in the MERG cohort of pregnant women with rash, recruited from the surveillance system from December/2015-June/2017. Exposure definition was based on a combination of longitudinal data from molecular, serologic (IgM and IgG3) and plaque reduction neutralization tests for ZIKV. Children were evaluated by a team of clinical specialists and by transfontanelle ultrasound and were classified as having microcephaly and/or other signs/symptoms consistent with congenital Zika syndrome (CZS). Risks of adverse outcomes were quantified according to the relative evidence of a ZIKV infection in pregnancy. Findings 376 women had confirmed and suspected exposure to ZIKV. Among evaluable children born to these mothers, 20% presented with an adverse outcome compatible with exposure to ZIKV during pregnancy. The absolute risk of microcephaly was 2.9% (11/376), of calcifications and/or ventriculomegaly was 7.2% (13/180), of additional neurologic alterations was 5.3% (13/245), of ophthalmologic abnormalities was 7% (15/214), and of dysphagia was 1.8% (4/226). Less than 1% of the children experienced abnormalities across all of the domains simultaneously. Interpretation: Although approximately one-fifth of children with confirmed and suspected exposure to ZIKV in pregnancy presented with at least one abnormality compatible with CZS, the manifestations presented more frequently in isolation than in combination. Due to the rare nature of some outcomes and the possibility of later manifestations, large scale individual participant data meta-analysis and the long-term evaluation of children are imperative to identify the full spectrum of this syndrome and to plan actions to reduce damages. The ability to meaningfully quantify the absolute and relative risks of Congenital Zika Syndrome is contingent on the accurate identification of ZIKV infections in pregnant women and the long-term follow-up of children at risk. This study builds on the evidence base on ZIKV in pregnancy by not only examining pregnancy and birth outcomes, but also considering later onset manifestations of Congenital Zika Syndrome, conducting a deep and standardized investigation of infant outcomes. In addition, it used unprecedented repeated testing and the use of multiple diagnostic platforms, including qRT-PCR, IgM and IgG3 ELISAs, and PRNTs to identify ZIKV cases. The absolute risk of microcephaly was 2.9%, of calcifications and/or ventriculomegaly was 7.2%, of additional neurologic alterations was 5.3%, of ophthalmologic abnormalities was 7% and of dysphagia was 1.8%. The manifestations presented more frequently in isolation than in combination (i.e., less than 1% of the children experienced abnormalities across all of the domains simultaneously). Although approximately one-fifth of children with confirmed and suspected exposure to ZIKV in pregnancy presented with at least one abnormality compatible with CZS, the manifestations presented more frequently in isolation than in combination
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13
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Marbán-Castro E, Goncé A, Fumadó V, Martínez MJ, López M, García-Otero L, Salazar L, Esteve C, Salvia D, Fortuny C, Eixarch E, Fuente-Moreno M, Pinazo MJ, Oliveira I, Rodríguez-Valero N, Requena-Méndez A, Camprubí D, Saco A, Castillo P, Vázquez A, de Ory F, Navero-Castillejos J, Casellas A, González R, Muñoz J, Gascón J, Ordi J, Menéndez C, Bardají A. Zika virus infection in pregnant travellers and impact on childhood neurodevelopment in the first two years of life: A prospective observational study. Travel Med Infect Dis 2021; 40:101985. [PMID: 33601028 DOI: 10.1016/j.tmaid.2021.101985] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The emergence of Zika virus (ZIKV) represents a threat with consequences on maternal and children's health. We aimed to assess the clinical and epidemiological characteristics of pregnant women returning from ZIKV affected areas, and the effects of maternal ZIKV infection on birth outcomes and children's health. METHODS This was a hospital-based prospective observational study conducted at the Hospital Clínic of Barcelona and Hospital Sant Joan de Déu, Barcelona, Spain, from January 2016 to February 2020. RESULTS One hundred and ninety-five pregnant women who had travelled to ZIKV affected areas during pregnancy were recruited. Four women (2.1%) had a confirmed ZIKV infection, 40 women (20.5%) a probable infection, and 151 (77.4%) were negative for ZIKV. Among the ZIKV confirmed cases, a pregnant woman suffered a miscarriage, highly plausible to be associated with ZIKV infection. Brain cysts and microcalcifications were detected in 7% of fetuses or infants from women with confirmed or probable ZIKV infection. Neurodevelopmental delay in the language function was found in 33.3% out of the 21 children evaluated. CONCLUSIONS These findings contribute to the understanding of ZIKV prevalence estimates, and the impact of maternal ZIKV infection on pregnancy outcomes and children's health. Results highlight the importance of long-term surveillance in pregnant travellers and their children.
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Affiliation(s)
| | - Anna Goncé
- Department of Maternal-Fetal Medicine, BCNatal - Barcelona Center of Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Victoria Fumadó
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Department of Tropical Pathology and Imported Diseases, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Miguel J Martínez
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Department of Clinical Microbiology, Hospital Clínic, Barcelona, Spain
| | - Marta López
- Department of Maternal-Fetal Medicine, BCNatal - Barcelona Center of Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Laura García-Otero
- Department of Maternal-Fetal Medicine, BCNatal - Barcelona Center of Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Laura Salazar
- Department of Maternal-Fetal Medicine, BCNatal - Barcelona Center of Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Carolina Esteve
- Department of Maternal-Fetal Medicine, BCNatal - Barcelona Center of Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Dolors Salvia
- Department of Maternal-Fetal Medicine, BCNatal - Barcelona Center of Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Claudia Fortuny
- Department of Tropical Pathology and Imported Diseases, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Elisenda Eixarch
- Department of Maternal-Fetal Medicine, BCNatal - Barcelona Center of Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | | | - María Jesús Pinazo
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Inés Oliveira
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | | | - Ana Requena-Méndez
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Department of Global Public Health, Karolinska Institutet, Sweden
| | - Daniel Camprubí
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Adela Saco
- Department of Pathology, Hospital Clínic, Barcelona, Spain
| | - Paola Castillo
- Department of Pathology, Hospital Clínic, Barcelona, Spain
| | - Ana Vázquez
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Fernando de Ory
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Aina Casellas
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Raquel González
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - José Muñoz
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Joaquim Gascón
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Jaume Ordi
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Department of Global Public Health, Karolinska Institutet, Sweden
| | - Clara Menéndez
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Azucena Bardají
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.
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Birth Defects and Long-Term Neurodevelopmental Abnormalities in Infants Born During the Zika Virus Epidemic in the Dominican Republic. Ann Glob Health 2021; 87:4. [PMID: 33505863 PMCID: PMC7792457 DOI: 10.5334/aogh.3095] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background: When acquired during pregnancy, Zika virus (ZIKV) infection can cause substantial fetal morbidity, however, little is known about the long-term neurodevelopmental abnormalities of infants with congenital ZIKV exposure without microcephaly at birth. Methods: We conducted a cross sectional study to characterize infants born with microcephaly, and a retrospective cohort study of infants who appeared well at birth, but had possible congenital ZIKV exposure. We analyzed data from the Dominican Ministry of Health’s (MoH) National System of Epidemiological Surveillance. Neurodevelopmental abnormalities were assessed by pediatric neurologists over an 18-month period using Denver Developmental Screening Test II. Results: Of 800 known live births from 1,364 women with suspected or confirmed ZIKV infection during pregnancy, 87 (11%) infants had confirmed microcephaly. Mean head circumference (HC) at birth was 28.1 cm (SD ± 2.1 cm) and 41% had a HC on the zero percentile for gestational age. Of 42 infants with possible congenital ZIKV exposure followed longitudinally, 52% had neurodevelopmental abnormalities, including two cases of postnatal onset microcephaly, during follow-up. Most abnormalities resolved, though two infants (4%) had neurodevelopmental abnormalities that were likely associated with ZIKV infection and persisted through 15–18 months. Conclusions: In the DR epidemic, 11% of infants born to women reported to the MoH with suspected or confirmed ZIKV during pregnancy had microcephaly. Some 4% of ZKV-exposed infants developed postnatal neurocognitive abnormalities. Monitoring of the cohort through late childhood and adolescence is needed.
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15
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Wilder-Smith A, Osman S. Public health emergencies of international concern: a historic overview. J Travel Med 2020; 27:6025447. [PMID: 33284964 PMCID: PMC7798963 DOI: 10.1093/jtm/taaa227] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/24/2020] [Accepted: 12/01/2020] [Indexed: 12/19/2022]
Abstract
RATIONALE The International Health Regulations (IHR) have been the governing framework for global health security since 2007. Declaring public health emergencies of international concern (PHEIC) is a cornerstone of the IHR. Here we review how PHEIC are formally declared, the diseases for which such declarations have been made from 2007 to 2020 and justifications for such declarations. KEY FINDINGS Six events were declared PHEIC between 2007 and 2020: the 2009 H1N1 influenza pandemic, Ebola (West African outbreak 2013-2015, outbreak in Democratic Republic of Congo 2018-2020), poliomyelitis (2014 to present), Zika (2016) and COVID-19 (2020 to present). Poliomyelitis is the longest PHEIC. Zika was the first PHEIC for an arboviral disease. For several other emerging diseases a PHEIC was not declared despite the fact that the public health impact of the event was considered serious and associated with potential for international spread. RECOMMENDATIONS The binary nature of a PHEIC declaration is often not helpful for events where a tiered or graded approach is needed. The strength of PHEIC declarations is the ability to rapidly mobilize international coordination, streamline funding and accelerate the advancement of the development of vaccines, therapeutics and diagnostics under emergency use authorization. The ultimate purpose of such declaration is to catalyse timely evidence-based action, to limit the public health and societal impacts of emerging and re-emerging disease risks while preventing unwarranted travel and trade restrictions.
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Affiliation(s)
- Annelies Wilder-Smith
- Global Health and Epidemiology, University of Umea, 901 87 Umea, Sweden.,Heidelberg Institute of Global Health, University of Heidelberg, Im Neuenheimer Feld 365, 6900 Heidelberg, Germany
| | - Sarah Osman
- Global Health and Epidemiology, University of Umea, 901 87 Umea, Sweden
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Ades AE, Brickley EB, Alexander N, Brown D, Jaenisch T, Miranda-Filho DDB, Pohl M, Rosenberger KD, Soriano-Arandes A, Thorne C, Ximenes RADA, de Araújo TVB, Avelino-Silva VI, Bethencourt Castillo SE, Borja Aburto VH, Brasil P, Christie CDC, de Souza WV, Gotuzzo H JE, Hoen B, Koopmans M, Martelli CMT, Martins Teixeira M, Marques ETA, Miranda MC, Montarroyos UR, Moreira ME, Morris JG, Rockx B, Saba Villarroel PM, Soria Segarra C, Tami A, Turchi MD, Giaquinto C, de Lamballerie X, Wilder-Smith A. Zika virus infection in pregnancy: a protocol for the joint analysis of the prospective cohort studies of the ZIKAlliance, ZikaPLAN and ZIKAction consortia. BMJ Open 2020; 10:e035307. [PMID: 33323426 PMCID: PMC7745317 DOI: 10.1136/bmjopen-2019-035307] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Zika virus (ZIKV) infection in pregnancy has been associated with microcephaly and severe neurological damage to the fetus. Our aim is to document the risks of adverse pregnancy and birth outcomes and the prevalence of laboratory markers of congenital infection in deliveries to women experiencing ZIKV infection during pregnancy, using data from European Commission-funded prospective cohort studies in 20 centres in 11 countries across Latin America and the Caribbean. METHODS AND ANALYSIS We will carry out a centre-by-centre analysis of the risks of adverse pregnancy and birth outcomes, comparing women with confirmed and suspected ZIKV infection in pregnancy to those with no evidence of infection in pregnancy. We will document the proportion of deliveries in which laboratory markers of congenital infection were present. Finally, we will investigate the associations of trimester of maternal infection in pregnancy, presence or absence of maternal symptoms of acute ZIKV infection and previous flavivirus infections with adverse outcomes and with markers of congenital infection. Centre-specific estimates will be pooled using a two-stage approach. ETHICS AND DISSEMINATION Ethical approval was obtained at each centre. Findings will be presented at international conferences and published in peer-reviewed open access journals and discussed with local public health officials and representatives of the national Ministries of Health, Pan American Health Organization and WHO involved with ZIKV prevention and control activities.
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Affiliation(s)
- A E Ades
- Department of Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Elizabeth B Brickley
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Neal Alexander
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - David Brown
- Flavivirus Reference Laboratory, Fundacão Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Thomas Jaenisch
- Department of Infectious Diseases, Section Clinical Tropical Medicine, UniversitatsKlinikum Heidelberg, Heidelberg, Germany
| | | | - Moritz Pohl
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Kerstin D Rosenberger
- Department of Infectious Diseases, Section Clinical Tropical Medicine, UniversitatsKlinikum Heidelberg, Heidelberg, Germany
| | - Antoni Soriano-Arandes
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Claire Thorne
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | | | | | - Vivian I Avelino-Silva
- Department of Infectious and Parasitic Diseases, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, São Paulo, Brazil
| | | | | | - Patrícia Brasil
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brazil
| | - Celia D C Christie
- Department of Child and Adolescent Health, University of the West Indies at Mona, Kingston, Jamaica
| | | | - Jose Eduardo Gotuzzo H
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Bruno Hoen
- INSERM Centre d'Investigation Clinique 1424, Centre Hospitalier Universitaire de Pointe-à-Pitre, Guadeloupe, France
- Faculté de Médecine Hyacinthe Bastaraud, Université des Antilles et de la Guyane, Pointe-à-Pitre, Guadeloupe, France
| | - Marion Koopmans
- Department of Viroscience, Erasmus Universiteit Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | | | | | - Ernesto T A Marques
- Instituto Aggeu Magalhães, Fundação Oswaldo Cruz, Recife, Brazil
- Department of Infectious Diseases and Microbiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | - Maria Elisabeth Moreira
- Figueira National Institute for Women's, Children's and Adolescents Health, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro, Brazil
| | - J Glenn Morris
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Barry Rockx
- Department of Viroscience, Erasmus Universiteit Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | | | - Carmen Soria Segarra
- Universidad Católica de Santiago de Guayaquil, Guayaquil, Guayas, Ecuador
- SOSECALI C., Ltda, Guayaquil, Ecuador
| | - Adriana Tami
- Facultad de Ciencias de la Salud, Universidad de Carabobo, Valencia, Venezuela
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, Groningen, The Netherlands
| | - Marília Dalva Turchi
- Institute of Tropical Pathology and Public Health, Federal University of Goias, Goiânia, Brazil
| | - Carlo Giaquinto
- Department of Woman's and Child's Health, Università degli Studi di Padova, Padova, Italy
| | - Xavier de Lamballerie
- Aix-Marseille Université Institut Universitaire de Technologie d'Aix-en-Provence, Aix-en-Provence, Provence-Alpes-Côte d'Azur, France
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Sanchez Clemente N, Brickley EB, Furquim de Almeida M, Witkin SS, Duarte Passos S. Can Zika Virus Infection in High Risk Pregnant Women Be Differentiated on the Basis of Symptoms? Viruses 2020; 12:v12111263. [PMID: 33167566 PMCID: PMC7694531 DOI: 10.3390/v12111263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/12/2020] [Accepted: 10/23/2020] [Indexed: 12/16/2022] Open
Abstract
Zika virus (ZIKV) infection in pregnancy is associated with congenital neurological abnormalities. Our understanding of the full clinical spectrum of ZIKV infection is incomplete. Using data from this prospective cohort study consisting of 650 women attending a high-risk pregnancy clinic during the Zika virus outbreak in Brazil, we investigated the extent to which specific symptoms can be utilized to differentiate ZIKV-infected pregnant women from those with other pregnancy-related problems. All were tested for ZIKV in urine by RT-qPCR. Demographic and clinical data including physical symptoms during follow-up were recorded and analyzed with respect to Zika virus exposure status. Forty-eight (7.4%) women were positive for ZIKV by RT-qPCR. The majority (70.8%) were asymptomatic, and only four ZIKV-positive women (8.3%) reported symptoms during pregnancy that met the WHO case definition. Zika-positive and -negative women reported similar frequencies of ZIKV-like symptoms (as per the WHO definition): fever (16.7% vs. 13.6%), arthralgia/arthritis (10.4% vs. 11.3%), rash (4.2% vs. 5.3%), and conjunctivitis (2.1% vs. 3.2%). Most pregnant women positive for ZIKV in urine are asymptomatic and do not deliver a baby with microcephaly. Physical symptoms alone did not differentiate between high-risk pregnant women positive or negative for ZIKV.
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Affiliation(s)
- Nuria Sanchez Clemente
- Department of Epidemiology, University of São Paulo School of Public Health, São Paulo 01246-904, Brazil;
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
- Correspondence:
| | - Elizabeth B. Brickley
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
| | - Marcia Furquim de Almeida
- Department of Epidemiology, University of São Paulo School of Public Health, São Paulo 01246-904, Brazil;
| | - Steven S. Witkin
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY 10065, USA;
| | - Saulo Duarte Passos
- Jundiaí Medical School, Jundiaí University, Jundiaí, São Paulo 13202-550, Brazil;
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18
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Angelo KM, Stoney RJ, Brun-Cottan G, Leder K, Grobusch MP, Hochberg N, Kuhn S, Bottieau E, Schlagenhauf P, Chen L, Hynes NA, Perez CP, Mockenhaupt FP, Molina I, Crespillo-Andújar C, Malvy D, Caumes E, Plourde P, Shaw M, McCarthy AE, Piper-Jenks N, Connor BA, Hamer DH, Wilder-Smith A. Zika among international travellers presenting to GeoSentinel sites, 2012-2019: implications for clinical practice. J Travel Med 2020; 27:5824831. [PMID: 32330261 PMCID: PMC7604850 DOI: 10.1093/jtm/taaa061] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION International travellers contribute to the rapid spread of Zika virus (ZIKV) and its sentinel identification globally. We describe ZIKV infections among international travellers seen at GeoSentinel sites with a focus on ZIKV acquired in the Americas and the Caribbean, describe countries of exposure and traveller characteristics, and assess ZIKV diagnostic testing by site. METHODS Records with an international travel-related diagnosis of confirmed or probable ZIKV from January 2012 through December 2019 reported to GeoSentinel with a recorded illness onset date were included to show reported cases over time. Records from March 2016 through December 2019 with an exposure region of the Americas or the Caribbean were included in the descriptive analysis. A survey was conducted to assess the availability, accessibility and utilization of ZIKV diagnostic tests at GeoSentinel sites. RESULTS GeoSentinel sites reported 525 ZIKV cases from 2012 through 2019. Between 2012 and 2014, eight cases were reported, and all were acquired in Asia or Oceania. After 2014, most cases were acquired in the Americas or the Caribbean, a large decline in ZIKV cases occurred in 2018-19.Between March 2016 and December 2019, 423 patients acquired ZIKV in the Americas or the Caribbean, peak reporting to these regions occurred in 2016 [330 cases (78%)]. The median age was 36 years (range: 3-92); 63% were female. The most frequent region of exposure was the Caribbean (60%). Thirteen travellers were pregnant during or after travel; one had a sexually acquired ZIKV infection. There was one case of fetal anomaly and two travellers with Guillain-Barré syndrome. GeoSentinel sites reported various challenges to diagnose ZIKV effectively. CONCLUSION ZIKV should remain a consideration for travellers returning from areas with risk of ZIKV transmission. Travellers should discuss their travel plans with their healthcare providers to ensure ZIKV prevention measures are taken.
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Affiliation(s)
- Kristina M Angelo
- Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30329, USA
| | - Rhett J Stoney
- Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30329, USA
| | - Gaelle Brun-Cottan
- Department of Medicine, Boston University School of Medicine, 72 E Concord St, Boston, MA 02118, USA
| | - Karin Leder
- School of Public Health and Preventive Medicine, Victorian Infectious Disease Service, Royal Melbourne Hospital, Doherty Institute for Infection and Immunity, Monash University, 300 Grattan St, Parkville 3050, Australia
| | - Martin P Grobusch
- Center for Tropical Medicine and Travel Medicine, Amsterdam University Medical Centers, University of Amsterdam, 1012 WX Amsterdam, The Netherlands
| | - Natasha Hochberg
- Department of Pediatrics, Boston University School of Medicine, 72 E Concord St, Boston, MA 02118, USA
| | - Susan Kuhn
- Department of Pediatrics, Alberta Health Services, 10101 Southport Rd SW, Calgary AB T2W 3N2, Canada
| | - Emmanuel Bottieau
- Department of Clinical Sciences, Institute of Tropical Medicine, Kronenburgstraat 43, 2000 Antwerp, Belgium
| | - Patricia Schlagenhauf
- WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Rämistrasse 71, 8006 Zurich, Switzerland
| | - Lin Chen
- Division of Infectious Diseases and Travel Medicine, Mount Auburn Hospital, Cambridge and Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - Noreen A Hynes
- Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, USA
| | - Cecilia Perret Perez
- School of Medicine, Universidad Catolica de Chile, Av Libertador Bernardo O'Higgins 340, Santiago, Santiago Metropolitan, Chile
| | - Frank P Mockenhaupt
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Tropical Medicine and International Health, Augustenburger Pl. 1, 13353 Berlin, Germany
| | - Israel Molina
- Department of Infectious Diseases, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona, PROSICS, Campus de la UAB, Plaça Cívica, 08193, Barcelona, Spain
| | - Clara Crespillo-Andújar
- National Referral Unit for Tropical and Travel Medicine, Department of Internal Medicine, University Hospital La Paz-Carlos III, Paseo de la Castellana, 261, 28046 Madrid, Spain
| | - Denis Malvy
- Department for Infectious Diseases and Tropical Medicine, University Hospital Centre of Bordeaux, and Inserm 1219, University of Bordeaux, 146 Rue Léo Saignat, 33076 Bordeaux, France
| | - Eric Caumes
- Hôpital Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, France
| | - Pierre Plourde
- University of Manitoba, 66 Chancellors Cir, Winnipeg MB R3T 2N2, Canada
| | - Marc Shaw
- James Cook University, 1 James Cook Dr, Douglas, Townsville 4811, Australia.,Worldwise Travellers' Health Centres, 18 Saint Marks Road, Remuera, Auckland 1050, New Zealand
| | - Anne E McCarthy
- Department of Medicine, Ottawa Hospital, University of Ottawa, 75 Laurier Ave E, Ottawa K1N 6N5, Canada
| | | | - Bradley A Connor
- The New York Center for Travel and Tropical Medicine, Weill Cornell Medical College, 1300 York Ave, New York, NY 10065, USA
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, 715 Albany St, Boston, MA 02118, USA.,Section of Infectious Diseases, Department of Medicine, Boston Medical Center, One Boston Medical Center Pl, Boston, MA 02118, USA
| | - Annelies Wilder-Smith
- Department of Epidemiology and Global Health, University of Umea, Petrus Laestadius Väg, 901 87, Umeå, Sweden.,Department for Disease Control, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK
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Yen PS, Failloux AB. A Review: Wolbachia-Based Population Replacement for Mosquito Control Shares Common Points with Genetically Modified Control Approaches. Pathogens 2020; 9:E404. [PMID: 32456036 PMCID: PMC7281599 DOI: 10.3390/pathogens9050404] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 12/13/2022] Open
Abstract
The growing expansion of mosquito vectors has made mosquito-borne arboviral diseases a global threat to public health, and the lack of licensed vaccines and treatments highlight the urgent need for efficient mosquito vector control. Compared to genetically modified control strategies, the intracellular bacterium Wolbachia, endowing a pathogen-blocking phenotype, is considered an environmentally friendly strategy to replace the target population for controlling arboviral diseases. However, the incomplete knowledge regarding the pathogen-blocking mechanism weakens the reliability of a Wolbachia-based population replacement strategy. Wolbachia infections are also vulnerable to environmental factors, temperature, and host diet, affecting their densities in mosquitoes and thus the virus-blocking phenotype. Here, we review the properties of the Wolbachia strategy as an approach to control mosquito populations in comparison with genetically modified control methods. Both strategies tend to limit arbovirus infections but increase the risk of selecting arbovirus escape mutants, rendering these strategies less reliable.
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Affiliation(s)
- Pei-Shi Yen
- Unit Arboviruses and Insect Vectors, Department of Virology, Institut Pasteur, F-75724 Paris, France
| | - Anna-Bella Failloux
- Unit Arboviruses and Insect Vectors, Department of Virology, Institut Pasteur, F-75724 Paris, France
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20
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Collins MH, Zepeda O, Blette B, Jadi R, Morales M, Pérez R, Liou GJA, Montoya-Cruz M, Harris E, Becker-Dreps S, de Silva AM, Stringer J, Bucardo F, Stringer E. Serologic surveillance of maternal Zika infection in a prospective cohort in Leon, Nicaragua during the peak of the Zika epidemic. PLoS One 2020; 15:e0230692. [PMID: 32243482 PMCID: PMC7122769 DOI: 10.1371/journal.pone.0230692] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/05/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Zika virus caused thousands of congenital anomalies during a recent epidemic. Because Zika emerged in areas endemic for dengue and these related flaviviruses elicit cross-reactive antibodies, it is challenging to serologically monitor pregnant women for Zika infection. METHODS A prospective cohort of 253 pregnant women was established in León, Nicaragua. Women were followed during prenatal care through delivery. Serologic specimens were obtained at each visit, and birth outcome was recorded. Established flavivirus serologic methods were adapted to determine Zika seroprevalence, and a stepwise testing algorithm estimated timing of Zika infection in relation to pregnancy. RESULTS Zika seroprevalence was approximately 59% among women tested. Neutralization testing was highly concordant with Zika NS1 BOB results. Per study algorithm, 21% (40/187) of women were classified as experiencing Incident ZIKV infection during pregnancy. Importantly, the Incident ZIKV group included mostly women pregnant during the 2016 Zika epidemic peak and the only 3 subjects in the cohort with RT-PCR-confirmed infections. Approximately 17% of births had complications; 1.5% (3/194) manifesting clinical criteria of congenital Zika syndrome, one was RT-PCR-confirmed as a case of congenital Zika syndrome. Adverse birth outcome did not correlate with timing of Zika infection. CONCLUSIONS By leveraging prenatal care systems, we developed a simple algorithm for identifying women who were likely infected by Zika during pregnancy.
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Affiliation(s)
- Matthew H. Collins
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Omar Zepeda
- Department of Microbiology, Faculty of Medical Science, National Autonomous University of Nicaragua, León UNAN-León, Managua, Nicaragua
| | - Bryan Blette
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Ramesh Jadi
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Marlen Morales
- Department of Microbiology, Faculty of Medical Science, National Autonomous University of Nicaragua, León UNAN-León, Managua, Nicaragua
| | - Rigoberto Pérez
- Department of Obstetrics and Gynecology, Faculty of Medical Science, National Autonomous University of Nicaragua, León UNAN-León, Managua, Nicaragua
| | - Guei-Jiun Alice Liou
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Magelda Montoya-Cruz
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, CA, United States of America
| | - Eva Harris
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, CA, United States of America
| | - Sylvia Becker-Dreps
- Department of Family Medicine and Epidemiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Aravinda M. de Silva
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Jeffrey Stringer
- Division of Global Women’s Health, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Filemon Bucardo
- Department of Microbiology, Faculty of Medical Science, National Autonomous University of Nicaragua, León UNAN-León, Managua, Nicaragua
| | - Elizabeth Stringer
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
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21
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Differential Pattern of Soluble Immune Markers in Asymptomatic Dengue, West Nile and Zika Virus Infections. Sci Rep 2019; 9:17172. [PMID: 31748599 PMCID: PMC6868147 DOI: 10.1038/s41598-019-53645-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/04/2019] [Indexed: 01/14/2023] Open
Abstract
Infections with dengue virus (DENV), West Nile virus (WNV) and Zika virus (ZIKV) usually present similar mild symptoms at early stages, and most infections (~80%) are asymptomatic. However, these infections may progress to severe disease with different clinical manifestations. In this study we attempted to identify unique characteristics for each infection at the presymptomatic/asymptomatic stage of infection and compared levels of soluble immune markers that have been shown to be altered during clinical course of these viral infections. Levels of soluble markers were determined by Luminex-based assays or by ELISA in plasma samples from asymptomatic blood donors who were reactive for RNA from DENV (n = 71), WNV (n = 52) or ZIKV (n = 44), and a control or non-infected (NI) group (n = 22). Results showed that even in the absence of symptoms, increased interleukin (IL) levels of IL-12, IL-17, IL-10, IL-5, CXCL9, E-Selectin and ST2/IL-1R4; and decreased levels of IL-13 and CD40 were found in all flavivirus group samples, compared to those from NI donors. DENV-infected donors demonstrated variation in expression of IL-1ra and IL-2; WNV-infected donors demonstrated variation in expression of IL-1ra, P-Selectin, IL-4 and IL-5; ZIKV-infected donors demonstrated variation in expression of IL-1ra, P-Selectin, IL-4, RANK-L, CD40L and C3a. The findings suggest that, even in the presymptomatic/asymptomatic phase of the infection, different immunomodulation profiles were associated with DENV, WNV and ZIKV infections.
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22
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Ximenes RADA, Miranda-Filho DDB, Brickley EB, Montarroyos UR, Martelli CMT, de Araújo TVB, Rodrigues LC, de Albuquerque MDFPM, de Souza WV, Castanha PMDS, França RFO, Dhália R, Marques ETA. Zika virus infection in pregnancy: Establishing a case definition for clinical research on pregnant women with rash in an active transmission setting. PLoS Negl Trop Dis 2019; 13:e0007763. [PMID: 31589611 PMCID: PMC6797234 DOI: 10.1371/journal.pntd.0007763] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 10/17/2019] [Accepted: 09/08/2019] [Indexed: 12/26/2022] Open
Abstract
Defining cases of Zika virus (ZIKV) infection is a critical challenge for epidemiological research. Due to ZIKV's overlapping clinical features and potential immunologic cross-reactivity with other flaviviruses and the current lack of an optimal ZIKV-specific diagnostic assay, varying approaches for identifying ZIKV infections have been employed to date. This paper presents the laboratory results and diagnostic criteria developed by the Microcephaly Epidemic Research Group for defining cases of maternal ZIKV infection in a cohort of pregnant women with rash (N = 694) recruited during the declining 2015-2017 epidemic in northeast Brazil. For this investigation, we tested maternal sera for ZIKV by quantitative reverse transcription polymerase chain reaction (qRT-PCR), Immunoglobulin (Ig) M and IgG3 enzyme-linked immunosorbent assays (ELISAs), and Plaque Reduction Neutralization Test (PRNT50). Overall, 23.8% of participants tested positive by qRT-PCR during pregnancy (range of detection: 0-72 days after rash onset). However, the inter-assay concordance was lower than expected. Among women with qRT-PCR-confirmed ZIKV and further testing, only 10.1% had positive IgM tests within 90 days of rash, and only 48.5% had ZIKV-specific PRNT50 titers ≥20 within 1 year of rash. Given the complexity of these data, we convened a panel of experts to propose an algorithm for identifying ZIKV infections in pregnancy based on all available lines of evidence. When the diagnostic algorithm was applied to the cohort, 26.9% of participants were classified as having robust evidence of a ZIKV infection during pregnancy, 4.0% as having moderate evidence, 13.3% as having limited evidence of a ZIKV infection but with uncertain timing, and 19.5% as having evidence of an unspecified flavivirus infection before or during pregnancy. Our findings suggest that integrating longitudinal data from nucleic acid and serologic testing may enhance diagnostic sensitivity and underscore the need for an on-going dialogue regarding the optimization of strategies for defining cases of ZIKV in research.
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Affiliation(s)
- Ricardo Arraes de Alencar Ximenes
- Departamento de Medicina Tropical, Universidade Federal de Pernambuco, Recife, PE, Brasil
- Departamento de Medicina Interna, Universidade de Pernambuco, Recife, PE, Brasil
| | | | - Elizabeth B. Brickley
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | | | - Laura C. Rodrigues
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | - Priscila Mayrelle da Silva Castanha
- Instituto Aggeu Magalhães, Fundação Oswaldo Cruz, Recife, PE, Brasil
- Department of Infectious Diseases and Microbiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Faculdade de Ciências Médicas, Universidade de Pernambuco, Recife, PE, Brasil
| | | | - Rafael Dhália
- Instituto Aggeu Magalhães, Fundação Oswaldo Cruz, Recife, PE, Brasil
| | - Ernesto T. A. Marques
- Instituto Aggeu Magalhães, Fundação Oswaldo Cruz, Recife, PE, Brasil
- Department of Infectious Diseases and Microbiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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23
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Efficient transplacental IgG transfer in women infected with Zika virus during pregnancy. PLoS Negl Trop Dis 2019; 13:e0007648. [PMID: 31449521 PMCID: PMC6730934 DOI: 10.1371/journal.pntd.0007648] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 09/06/2019] [Accepted: 07/22/2019] [Indexed: 12/28/2022] Open
Abstract
Zika virus (ZIKV) is a newly-identified infectious cause of congenital disease. Transplacental transfer of maternal IgG to the fetus plays an important role in preventing many neonatal infections. However, antibody transfer may also have negative consequences, such as mediating enhancement of flavivirus infections in early life, or trafficking of virus immune complexes to the fetal compartment. ZIKV infection produces placental pathology which could lead to impaired IgG transfer efficiency as occurs in other maternal infections, such as HIV-1 and malaria. In this study, we asked whether ZIKV infection during pregnancy impairs transplacental transfer of IgG. We enrolled pregnant women with fever or rash in a prospective cohort in Vitoria, Brazil during the recent ZIKV epidemic. ZIKV and dengue virus (DENV)-specific IgG, ZIKV and DENV neutralizing antibodies, and routine vaccine antigen-specific IgG were measured in maternal samples collected around delivery and 20 paired cord blood samples. We concluded that 8 of these mothers were infected with ZIKV during pregnancy and 12 were ZIKV-uninfected. The magnitude of flavivirus-specific IgG, neutralizing antibody, and vaccine-elicited IgG were highly correlated between maternal plasma and infant cord blood in both ZIKV-infected and -uninfected mother-infant pairs. Moreover, there was no difference in the magnitude of plasma flavivirus-specific IgG levels between mothers and infants regardless of ZIKV infection status. Our data suggests that maternal ZIKV infection during pregnancy does not impair the efficiency of placental transfer of flavivirus-specific, functional, and vaccine-elicited IgG. These findings have implications for the neonatal outomes of maternal ZIKV infection and optimal administration of antibody-based ZIKV vaccines and therapeutics.
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Fandiño-Cárdenas M, Idrovo AJ, Velandia R, Molina-Franky J, Alvarado-Socarras JL. Zika Virus Infection during Pregnancy and Sensorineural Hearing Loss among Children at 3 and 24 Months Post-Partum. J Trop Pediatr 2019; 65:328-335. [PMID: 30252119 DOI: 10.1093/tropej/fmy055] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The objectives of this study were to describe the findings of the auditory screening in children of mothers with ZIKV during pregnancy or suspicious of congenital ZIKV, and to determine whether hearing loss was in the first 2 years in life, regardless of whether microcephaly was also present. METHODS This is a cases report. The information was collected and recorded in a database between January 2016 and April 2018. We perform two auditory tests to 3 and 24 months of life. The study was developed in Aguachica (Cesar, Colombia). It is considered a high-risk area for ZIKV infection. Participants included children of mothers with confirmed ZIKV during pregnancy or suspicious of congenital ZIKV exposure of ZIKV infection during an epidemic period in a tropical area. We defined a positive case according to the epidemiological definition and clinical criteria based on maternal symptoms. However, other children of mothers without clinical signs of Zika were evaluated at the same time. The main outcome was the presence of sensorineural hearing loss. RESULTS The median age in the study group (n = 43) was 3.5 months (rank: 0-6) and the comparison group (n: 23, children of mothers without clinical signs of ZIKV) was 3 months (rank: 0-12). Screening hearing test was done using distortion product otoacustic emissions. At 3 months follow-up, children were evaluated using distortion product otoacustic emissions and automatized auditory brainstem response. None of the patients evaluated in this study were found to have sensorineural hearing loss. CONCLUSIONS We did not find hearing loss during the first 2 years in the children whose mother showed Zika during pregnancy. We recommend these children must be assessed to closed because there is a high risk the hearing loss as it usually may occur with CMV.
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Affiliation(s)
- Marcela Fandiño-Cárdenas
- Pediatric otolaryngology, Department of Pediatrics, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Alvaro J Idrovo
- Associate Professor, Public Health Department School of Medicine, Universidad Industrial de Santander, Bucaramanga, Santander, Colombia
| | | | | | - Jorge L Alvarado-Socarras
- Pediatric otolaryngology, Department of Pediatrics, Fundación Cardiovascular de Colombia, Floridablanca, Colombia.,Neonatologist Researcher. Neonatal UCI Director Fundacion Cardiovascular de Colombia, RECOLZIKA Red Colombiana de Colaboración en Zika
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25
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Abstract
We present a model to optimise a vaccination campaign aiming to prevent or to curb a Zika virus outbreak. We show that the optimum vaccination strategy to reduce the number of cases by a mass vaccination campaign should start when the Aedes mosquitoes' density reaches the threshold of 1.5 mosquitoes per humans, the moment the reproduction number crosses one. The maximum time it is advisable to wait for the introduction of a vaccination campaign is when the first ZIKV case is identified, although this would not be as effective to minimise the number of infections as when the mosquitoes' density crosses the critical threshold. This suboptimum strategy, however, would still curb the outbreak. In both cases, the catch up strategy should aim to vaccinate at least 25% of the target population during a concentrated effort of 1 month immediately after identifying the threshold. This is the time taken to accumulate the herd immunity threshold of 56.5%. These calculations were done based on theoretical assumptions that vaccine implementation would be feasible within a very short time frame.
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26
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Pomar L, Musso D, Malinger G, Vouga M, Panchaud A, Baud D. Zika virus during pregnancy: From maternal exposure to congenital Zika virus syndrome. Prenat Diagn 2019; 39:420-430. [PMID: 30866073 DOI: 10.1002/pd.5446] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 02/27/2019] [Accepted: 03/06/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Léo Pomar
- Department "Woman-Mother-Child", Lausanne University Hospital, Materno-Fetal and Obstetrics Research Unit, Lausanne, Switzerland
| | - Didier Musso
- Aix Marseille University, IRD, AP-HM, SSA, VITROME, IHU-Méditerranée infection, Marseille, France
- Private practitioner, Punaauia, Tahiti, French Polynesia
| | - Gustavo Malinger
- Division of Ultrasound in Obstetrics & Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center & Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Manon Vouga
- Department "Woman-Mother-Child", Lausanne University Hospital, Materno-Fetal and Obstetrics Research Unit, Lausanne, Switzerland
| | - Alice Panchaud
- School of Pharmaceutical Sciences, Geneva University and Service of Pharmacy, Lausanne University Hospital, Lausanne, Switzerland
| | - David Baud
- Department "Woman-Mother-Child", Lausanne University Hospital, Materno-Fetal and Obstetrics Research Unit, Lausanne, Switzerland
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27
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Zika virus: Epidemiological surveillance of the Mexican Institute of Social Security. PLoS One 2019; 14:e0212114. [PMID: 30742671 PMCID: PMC6370238 DOI: 10.1371/journal.pone.0212114] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 01/27/2019] [Indexed: 11/21/2022] Open
Abstract
Introduction At the end of 2015, the first cases of Zika were identified in southern Mexico. During 2016, Zika spread as an outbreak to a large part of the country's coastal zones. Methodology The Zika epidemiological surveillance system records cases with clinical symptoms of Zika virus disease (ZVD) and those confirmed by means of a reverse polymerase chain reaction (RT-PCR) assay. This report includes the suspected and confirmed cases from 2016. Incidence rates were estimated by region and in pregnant women based on the proportion of confirmed cases. Results In total, 43,725 suspected cases of ZVD were reported. The overall incidence of suspected cases of ZVD was 82.0 per 100,000 individuals and 25.3 per 100,000 Zika cases. There were 4,168 pregnant women with suspected symptoms of ZVD, of which infection was confirmed in 1,082 (26%). The estimated incidence rate of ZVD for pregnant women nationwide was 186.1 positive Zika cases per 100,000 pregnant women. Conclusions The incidence of Zika in Mexico is higher than that reported previously in the National System of Epidemiological Surveillance. Positive cases of Zika must be estimated and reported.
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Vannice KS, Cassetti MC, Eisinger RW, Hombach J, Knezevic I, Marston HD, Wilder-Smith A, Cavaleri M, Krause PR. Demonstrating vaccine effectiveness during a waning epidemic: A WHO/NIH meeting report on approaches to development and licensure of Zika vaccine candidates. Vaccine 2019; 37:863-868. [PMID: 30639461 PMCID: PMC6357529 DOI: 10.1016/j.vaccine.2018.12.040] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/13/2018] [Accepted: 12/18/2018] [Indexed: 11/30/2022]
Abstract
Since its peak in early 2016, the incidence of Zika virus (ZIKV) cases has declined to such low levels that Phase 3 field efficacy trials may be infeasible. While great progress was made to rapidly advance several vaccine candidates into Phase 1 and 2 clinical trials, in the absence of sustained viral transmission it may be difficult to evaluate the effectiveness of ZIKV vaccine candidates by conducting traditional clinical disease endpoint efficacy studies. However, ZIKV is still circulating at low levels in some areas and is likely to re-emerge in naïve populations or in sites of prior epidemics once population immunity wanes. Therefore, the public health need for a ZIKV vaccine remains. To facilitate continued ZIKV vaccine development efforts, the World Health Organization's Initiative for Vaccine Research and the National Institutes of Health's National Institute of Allergy and Infectious Diseases co-hosted a meeting of experts in March 2018 to identify strategies to demonstrate vaccine effectiveness in view of waning ZIKV disease incidence. This paper outlines points for consideration for developers, regulators, and other stakeholders working towards a licensed ZIKV vaccine. These deliberations may also be applicable to development of vaccines for other emerging infections where the size, unpredictability, and ephemeral nature of outbreaks makes clinical disease endpoint efficacy trials to demonstrate vaccine effectiveness infeasible.
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Affiliation(s)
- Kirsten S Vannice
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland.
| | - M Cristina Cassetti
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Robert W Eisinger
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Joachim Hombach
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | - Ivana Knezevic
- Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland
| | - Hilary D Marston
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Annelies Wilder-Smith
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | | | - Philip R Krause
- Center for Biologics Evaluation and Research, Food and Drug Administration, Rockville, MD, USA
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Animal Models of Zika Virus Infection during Pregnancy. Viruses 2018; 10:v10110598. [PMID: 30384472 PMCID: PMC6266710 DOI: 10.3390/v10110598] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 10/28/2018] [Accepted: 10/30/2018] [Indexed: 02/06/2023] Open
Abstract
Zika virus (ZIKV) emerged suddenly in the Americas in 2015 and was associated with a widespread outbreak of microcephaly and other severe congenital abnormalities in infants born to mothers infected during pregnancy. Vertical transmission of ZIKV in humans was confirmed when viral RNA was detected in fetal and placental tissues, and this outcome has been recapitulated experimentally in animals. Unlike other flaviviruses, ZIKV is both arthropod- and sexually-transmitted, and has a broad tissue tropism in humans, including multiple tissues of the reproductive tract. The threats posed by ZIKV have prompted the development of multiple in vivo models to better understand the pathogenesis of ZIKV, particularly during pregnancy. Here, we review the progress on animal models of ZIKV infection during pregnancy. These studies have generated a foundation of insights into the biology of ZIKV, and provide a means for evaluating vaccines and therapeutics.
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Wilder-Smith A, Chang CR, Leong WY. Zika in travellers 1947-2017: a systematic review. J Travel Med 2018; 25:5054972. [PMID: 30016469 DOI: 10.1093/jtm/tay044] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 06/21/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Travellers contributed substantially to the rapid spread of Zika virus (ZIKV). They act as sentinel and may unmask ongoing ZIKV transmission in countries where outbreaks have not yet been reported. Our objectives were to (i) describe the burden of ZIKV infections in international travellers over time; (ii) estimate the proportion of birth defects as a result of maternal ZIKV infection in travellers; (iii) track the extent of sexual transmission; (iv) summarize ZIKV infections in returning travellers as reported by the GeoSentinel network; and (v) identify countries without reports on local ZIKV transmission where travellers served as sentinel. METHODS We performed a systematic review from 1947 to April 2017 on travel-associated ZIKV infections. We also compared published reports on autochthonous ZIKV transmission in Asia with published reports on exportations from travellers in Asia. RESULTS Of 314 papers that fit the inclusion criteria, 61 were eligible for final analysis. There was an exponential increase in the number of reported ZIKV infected travellers from the years 2013 to 2016, which declined in 2017. Amongst pregnant women with ZIKV infection, (5%) resulted in a fetus or infant with ZIKV-associated birth defects. An estimated 1% of the total number of ZIKV cases reported in the USA and Europe were acquired through sexual transmission. Through the GeoSentinel network, five countries (Indonesia, Philippines, Thailand, Vietnam, Cameroon) were identified as sentinel markers where ZIKV was exported despite the absence of reported local transmission. CONCLUSIONS Mobility patterns and travel volumes can help to identify the most likely origin of importation, and also in predicting further propagation. Studies on pregnant returning travellers have contributed to a better understanding of the risk estimates of congenital Zika syndrome/microcephaly as a result of maternal ZIKV infection, and the relative contribution of sexual transmisison.
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Affiliation(s)
- Annelies Wilder-Smith
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Department of Global Health and Epidemiology, University of Umea, Umea, Sweden.,London School of Hygiene and Tropical Medicine, Department of Disease Control, London, UK
| | - Chui Rhong Chang
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Wei Yee Leong
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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