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Zika virus in Brazil: a new challenge for the national health system and nursing care.

The appearance and rapid spread of the ZIKA virus in Brazil and elsewhere in the Americas has received increasing attention in the popular media, and in authoritative publications and news updates of Brazilian and international health agencies. Currently, there is much information and disinformation on this new epidemic available to the public and healthcare professionals. To better inform healthcare providers, especially nurses involved in the area of maternal and child health, I have written this article which is based on the most recent information from the Ministry of Health of Brazil and the Oswaldo Cruz Foundation which conducts public health research throughout Brazil.

The Zika virus (ZIKV) is one of several mosquito-borne illnesses that have infected many people in Brazil over the decades. Annually, there are recurring epidemics of dengue fever. Also, yellow fever and malaria occasionally occur in Brazil, but they are no longer classified as epidemics. The main vector for dengue, yellow fever, and now the Zika virus is the Aedes aegypti mosquito. The Aedes aegypti mosquito is now receiving great attention from scientists and public health professionals because it spreads ZIKV, which appears to have serious neurological complications, in particular, microcephaly in infants.

In October of 2015, the Brazilian Ministry of Health received the first reports from the Pernambuco Secretariat of Health in Northeastern Brazil that there was an increase in the incidence of microcephaly in infants. Although, at that time, and currently, there is no causal proof that pregnant women who are infected with the Zika virus consequently have microcephalic babies, there is mounting correlational evidence in support of this assertion. First, the mothers giving birth to the babies with microcephaly lived in a region where there had been a Zika virus outbreak; second, more than 60 women who delivered microcephalic infants had reported to their clinician that they experienced a rash (a symptom of Zika infection) during their pregnancy; third, two women whose fetuses were observed to have microcephaly had ZIKV detected in their amniotic fluid and lastly, examinations of infants who had died with malformed heads were similar to infants who had died with microcephaly of mothers who were reported to have the Zika virus. There is considerable ongoing clinical research to confirm the presumed neurological complication of ZIKV.

Other recent research has focused on Zika transmission. The work of Dr. Myra Bonaldo from Oswaldo Cruz Institute and Evando Chagas of the (Brazilian) National Institute of Infectious Diseases has found the Zika virus in urine and saliva (Agencia Fiocruz de Noticia, 2016). Further studies are needed to assess the epidemiological relevance of these findings.

The most recent Zika virus update (February 13, 2016) of the Ministry of Health of Brazil suggests that there are many neurological outcomes associated with this growing epidemic. It was reported that nationwide there were 5280 cases of microcephaly and other neurological disorders associated with ZIKV infection. Responding to these findings, the Brazilian government has ordered mandatory PCR tests and made 250,000 test kits available in 23 Central Public Laboratories.

The Zika virus epidemic has profound implications for mothers and their children in Brazil.

The Zika virus epidemic has profound implications for mothers and their children in Brazil. A large group of children, perhaps a generation, has been called "the children of Zika." These are children with neurological complications of the infection--microcephaly being the most severe. Dr. Adriana Melo, a gynecologist, was one of the first health professionals to suspect the relationship between Zika and microcephaly (Melo, Malinger, Ximenes, Szejnfeld, Alves Sampaio, Bispo de Filippis, 2016). Two of her pregnant patients, who were diagnosed with fetal microcephaly and were part of the 'microcephaly cluster,' had suffered from symptoms related to ZIKV infection (Brasil Ministerio da Saude, 2016). Most likely these cases represented the first diagnoses of intrauterine transmission of the virus (Melo, et al., 2016). In an interview for Radis Magazine (REVISTA RADIS, 2016), Dr. Melo said that the time of ultrasonography for her patients became a moment of tension because it was a "moment of sentence." She and other health professionals are recommending that the children of mothers who are identified as potentially being infected by the Zika, should have special attention throughout the first year of their life. During this period, it is possible that other neurological symptoms, less severe than microcephaly, might appear. It is also recommended that these children be followed later by a multidisciplinary team for possible difficulties in speech and learning. This potential long-term monitoring by a healthcare team could be a challenge to the healthcare system. Therefore, the impact of ZIKA virus infection on mothers, children, families and the healthcare system, including nurses, could be far greater than expected.

Another issue affected by the ZIKA epidemic is pregnancy planning. In an interview for the O Estao de Sao Paulo newspaper on November 12, 2015, the director of the Department of Surveillance of Transmitted Disease in the Ministry of Health, Claudio Maierovitch, suggested that women in regions with high ZIKV prevalence should avoid getting pregnant (Formenti Ligia, 2015). His comments were severely criticized by people in the community and re-ignited a debate about public health programs violating individual rights. A more moderate recommendation is that women and their partners should wait until the second half of the year when there are less Aedes aegypti mosquitoes to try to become pregnant. Another practical recommendation is that Brazilians should use insect repellent and wear long-sleeved shirts and long pants to avoid mosquito bites. However, this is problematic in a largely tropical country with constantly high temperatures and humidity.

Finally, there is the complex discussion of the effectiveness of control measures that are being taken to eliminate the Aedes aegypti mosquitoes. Mosquito-fighting measures remain the main strategy in the short-term. The Brazilian Association of Public Health (ABRASCO, 2016) has opposed many government sponsored mosquito eradication efforts because after 40 years of these programs the mosquitoes remain. They argue that an investment in basic sanitation would be the best long-term solution. Overall, in Brazil only 55 percent of households are connected to sanitary sewer lines. Moreover, in the Northeast, the region with the highest number of recent births with microcephaly, more than one quarter (26 percent) of households have open sewers (Brasil. Instituto Brasileiro de Geografia e Estatistica, 2010). This situation has been an historical challenge to Brazil. The irregular distribution of drinking water in rural areas, or the periphery of large cities, forces people to store water at home in a precarious way that ultimately creates a breeding area for Aedes aegypti mosquitoes.

This year Brazil will receive thousands of tourists for the Olympic and Paralympic games. In the July and August period, weather conditions are less favorable for mosquito proliferation, but ZIKA virus transmission remains a major concern. While Brazil will attempt to take effective measures to control the mosquito population at this time, there are still many unanswered questions that will require long-term research efforts to resolve.

What is the real risk of transmission through other body fluids? At what time period of a pregnancy is a ZIKA infection must dangerous? How long after an infection can someone still transmit the virus? After the first infection, is a person immune to the virus? In addition to neurological changes, could the virus cause problems with other tissues?

From a public health perspective, there are three essential actions that must be taken to control and eventually eradicate the Zika virus in Brazil: (i) improve social and environmental conditions to eliminate mosquito breeding sites, (2) fund research to expand knowledge about the disease and develop a vaccine, and (3) provide health care and social support for those families who have children with permanent special needs resulting from ZIKA infection. We must remember that even after a vaccine is developed and more effective mosquito control efforts are in place, those individuals (and their families) whose lives have been permanently altered by the ZIKA virus must not be left behind.

References

Abrasco. Nota tecnica sobre microcefalia e doen^as vetoriais relacionadas ao Aedes aegypti: os perigos das abordagens com larvicidas e nebulizacoes quimicas--fumace. Em 02 de fevereiro de 2016 Avaliable at https://www. abrasco.org.br/site/2016/02/nota-tecnica-sobre-microcefalia-e-doencasvetoriais-relacionadas-ao-aedes-aegypti-os- perigos-das-abordagens-comlarvicidas-e-nebulizacoes-quimicas-fumace/ Access 15 de fevereiro 2016.

Agencia Fiocruz de Noticia. Fiocruz detecta presenta de virus Zika com potencial de infecto em saliva e urina. 05 de fevereiro de 2016 Disponivel em https://agencia.fiocruz.br/fiocruz-detecta-presenca-de-virus-zika-compotencial-de-infeccao-em-saliva-e-urina. Access in 15/02/2016.

Brasil. Instituto Brasileiro de Geografia e Estatistica. Pesquisa Nacional de Saneamento Basico 2008. Rio de Janeiro: 1BGE, 2010.

Brasil. Ministerio da Saude. Informe Epidemiologico n. 13. Avaliable at http://combateaedes.saude.gov.br/images/pdf/Microcefalias_1nforme_Epidemiologico_13_SE_06_2016_17fev2016.pdf . Access in 19th february 2016.

Formenti Ligia. Diretor do Ministerio da Saude aconselha que mulheres de PE adiem planos de gravidez. O Estado de S.Paulo, 12 de novembro de 2015.

Melo, A. S., Malinger, G., Ximenes, R., Szejnfeld, P. O., Alves Sampaio, S., Bispo de Filippis, A. M. Ultrasound Obstet Gynecol 2016; 47: 6-7.

REVISTA RAD1S fevereiro de 2016, p. 19

World Health Organization 2016. Zika virus. http://www.who.int/mediacentre/factsheets/zika/en/-accessed February 17th 2016

Michele Rocha Kadri is a researcher and instructor at the Oswaldo Cruz Foundation, Leonidas and Maria Deane Research Center in Manaus, Amazonas, Brazil. She is an expert in the study of infectious disease epidemics in Brazil.
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Author:Kadri, Michele Rocha
Publication:International Journal of Childbirth Education
Geographic Code:3BRAZ
Date:Apr 1, 2016
Words:1562
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