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Zika and Microcephaly: How Doctors Made the Link

News & Perspective Multispecialty

Zika and Microcephaly: How Doctors Made the Link

Sonya Collins and Brenda Goodman

February 04, 2016


The first ultrasound scans were devastating.

In grainy black and white, doctors peeking into the wombs of pregnant women in Brazil could see trouble.

The brains of their tiny patients weren’t keeping pace with the rest of their growth. And something was badly wrong. The brain’s inner chambers seemed enlarged and deformed, and other key structures were altered — a condition known as microcephaly.

Most puzzling to Adriana Melo, MD, PhD, an obstetrician and fetal medicine specialist in Campina Grande, Brazil, were the bright spots called calcifications that dotted the brain tissue.

“Since the first exams, when I started to see a strange pattern, I thought that this was something different, something new in Brazil,” Melo says. She says when the brain’s inner chambers are enlarged, it usually points to a genetic problem, but “…calcification suggests infection. So the combination of these findings was confusing.”

In an average year, a doctor in Brazil might see one or two pregnancies with birth defects like these. But by October, Melo had heard about more than 60 of these babies.

Fear took hold.

“There was a terrible rumor that vaccines were the cause,” Melo says. “And that was very hard for us, because people would talk about microcephaly and then someone would say, ‘Oh, just don’t get any vaccines,’” she says. “People started to believe that it was related.”

But Melo knew it had to be something else, and she raced to find it.

“We couldn’t just sit here,” she says. “I knew what I was seeing was something different, something new that we hadn’t seen before.”

Her first patient was a 34-year-old first-time mom. Melo had been her doctor from the beginning of her pregnancy. The woman had no risk factors for microcephaly. She didn’t smoke, didn’t drink, didn’t use drugs, and had no family history of genetic problems that might cause the condition.

What she did have was a rash and achy joints when she was about 8 weeks pregnant. Her symptoms had faded and she had seemingly recovered without a problem.


Source: Courtesy of Adriana Melo, MD

Nobody suspected Zika virus.

“We’ve had dengue here for years, and we just haven’t been that worried about that virus, and we thought this was going to be same,” Melo says.

Doing Detective Work

The virus was first discovered in a monkey in Uganda in 1947. It was only reported in humans about a dozen times for the next 50 years. Then in 2007, Zika infected about three-quarters of the population on the tiny island of Yap, between the Philippines and Papua New Guinea in the western Pacific Ocean. In 2013 the virus skipped east, where it caused another major outbreak on the islands of French Polynesia.

The virus seemed mild. About 80% of people who are infected never even know it. Those who do have mild symptoms, like a rash, joint pain, fever and red eyes, and they tend to recover quickly.

Melo says she first started hearing about Zika infections in Campina Grande in July. She and other doctors shrugged. It was a nuisance, but hardly unexpected in a tropical climate.

But as she tried to figure out what was affecting so many pregnant women at the same time, she remembered her patient’s rash and achy joints. Could it be Zika?

She read as much as she could about the virus. She learned it was neurotropic, meaning it likes to infect the nervous system. She also found two scientific reports that showed the same kind of brain damage in fetal cows and sheep after their mothers had been experimentally infected with viruses in the same family as Zika.

Melo knew she was on to something.

On Nov. 10, she used a long needle to draw samples of the pale amniotic fluid from two of her patients whose babies were showing signs of microcephaly. She sent them off for analysis.

On Thursday, as luck would have it, she had registered to attend a medical meeting in Sao Paulo –about 1,600 miles south of Campina Grande — on the development of the fetal brain.

She took her patients’ medical records and their ultrasound scans so other doctors could see them and weigh in.

There she met Gustavo Malinger, MD, director of the obstetrical ultrasound unit at the Tel Aviv Sourasky Medical Center in Israel. She knew Malinger to be “one of the greatest fetal brain experts in the world.”

He was interested, but he expressed doubts.

“He thought it was virtually impossible that this could be caused by a virus,” she says. “But I insisted we were seeing a pattern. That made an impression on him.”

He asked her if she could bring the patients to him so he could repeat the scans. She told him that no, the patients lived thousands of miles to the north, and it wouldn’t be possible.

But she knew this was a critical piece of evidence. She left Malinger and quickly called Brazil’s Ministry of Health — an agency that’s a bit like the Department of Health and Human Services in the U.S. — and convinced them to pay for plane tickets for the women to travel to Sao Paulo the next day.

“I performed the examinations in Sao Paulo,” Malinger says, after the doctors found a private hospital that allowed them to do ultrasounds and MRIs.

“The findings were very surprising,” he says. “Most of the brain structures were destroyed. Also the eyes were destroyed.” They were, he says, “without hope.”

Malinger did the exams on the Nov. 14. By the following Monday, Melo had her lab results back. The amniotic fluid around the babies was teeming with Zika virus.

“On Monday, when I gave him the results, he was truly taken aback. This was something,” Melo says. “It was the first time in the world that we had been able to detect Zika virus in amniotic fluid. And we had documented just how aggressive the virus was.”

The two later published their findings as a “Physician Alert” in the journal Ultrasound in Obstetrics and Gynecology.

‘We Needed to Say Something to Women’

Though local doctors had suspected Zika might be causing microcephaly since September, “every time we tried to broach the subject, we were criticized because we didn’t have any evidence,” Melo says.

Evidence in hand, Melo alerted the Ministry of Health. After laboratory tests found Zika virus in the amniotic fluid around a third baby, stillborn in the neighboring state of Ceara, the agency sounded the alarm.

A week later, the European Centre for Disease Prevention and Control put out the first international alert that the microcephaly cases in Brazil might be linked to Zika.

The Brazilian doctors were criticized for the warning. Even with Zika in the amniotic fluid, the virus has still never been found in the blood from a baby’s umbilical cord. And right now, there’s no biological theory to explain how the virus might be doing its dirty work.

“For this, you need long-term studies,” Melo says. “We all know that. But my concern was — why I wanted to get clarification of these cases — is because we needed to say something to women who are pregnant now,” she says.

“This is very serious. They have to have a chance.”

For many of her patients, the discovery was simply too late. After learning of the microcephaly, many women wanted to abort their pregnancies, but abortion is against the law in Brazil.

But at least the government started to advise pregnant women to protect themselves with long pants, long sleeves, and socks, and to put screens on their windows — something that’s rarely done in Brazil. Health officials have also started a campaign called “Sabado da Faxina,” or “Cleaning Saturday,” to get people to walk around their houses to check for trash and small pools of still water, even water that might collect in sidewalk cracks.

“There’s no such thing as enough protection,” Melo says.

Besides the infants who are obviously affected, Malinger predicts something worse.

“First they will diagnose the children who are most severely affected. In time, after 2 or 3 years, they will find other children who are sick — they will be blind, they will have hearing problems, they will have cardiac problems. It won’t only affect the brain. It will be a multi-organ disease.” Melo stays in touch with mothers who have given birth to babies with microcephaly, privately, on social media.

“These mothers’ situations are very hard right now,” she says. “It’s the uncertainty. Because there’s nothing we can tell them about the prognosis of these children, so it’s very difficult for a mother who doesn’t know if her child is going to sit up, if her child is going to walk.”

The Brazilian Ministry of Health has pledged to follow the microcephaly babies. They are offering families physical therapy and other programs to help the children and try to minimize the consequences.

“These services are going to be overloaded. And this isn’t [just] a problem with Brazil. Nobody can say ‘Oh, Brazil isn’t prepared for this.’ No country is prepared for this,” Melo says.


Adriana Melo, MD, PhD, President, Professor Joaquim Amorim Neto Research Institute, Campina Grande, Paraiba, Brazil.

Gustavo Malinger, MD, director of the obstetrical ultrasound unit at the Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Ultrasound in Obstetrics and Gynecology, January, 2016.

Morbidity and Mortality Weekly Report, January 22, 2016.

European Center for Disease Prevention and Control, November 24, 2015.

Emerging Infectious Diseases, September 15, 2009.



Aggregation of Systemic Lupus and Other Autoimmune Diseases

This population-based study looks at the development of autoimmune diseases in first-degree relatives and spouses of patients with systemic lupus erythematosus.




Importance  Relatives of patients with systemic lupus erythematosus (SLE) appear to be at higher risk of SLE and other autoimmune diseases, but estimates of individual familial risks are largely unavailable or unreliable. Furthermore, relative contributions of genetic, shared, and unshared environmental factors to SLE susceptibility remain unclear.

Objective  To examine familial aggregation and heritability of SLE and the relative risks (RRs) of other autoimmune diseases in relatives of patients with SLE.

Design, Setting, and Participants  A population-based family study using the Taiwan National Health Insurance Research Database was conducted. Participants included all individuals (N = 23 658 577) registered with that database in 2010; of these, 18 283 had SLE. We identified 21 009 551 parent-child relationships, 17 168 340 full sibling pairs, and 342 066 twin pairs. Diagnoses of SLE were ascertained from March 1, 1995, to December 31, 2010, and analysis was conducted between March 1 and August 15, 2014.

Main Outcomes and Measures  The prevalence and RRs of SLE and other autoimmune diseases in relatives and spouses of patients with SLE as well as the relative contributions of heritability, shared, and nonshared environmental factors to SLE susceptibility.

Results  Among the more than 23 million participants, the RRs (95% CIs) for SLE were 315.94 (210.66-473.82) for twins of the patients, 23.68 (20.13-27.84) for siblings, 11.44 (9.74-13.43) for parents, 14.42 (12.45-16.70) for offspring, and 4.44 (2.38-8.30) for spouses without genetic similarity. The accountability for phenotypic variance of SLE was 43.9% for heritability, 25.8% for shared environmental factors, and 30.3% for nonshared environmental factors. The RRs (95% CIs) in individuals with a first-degree relative with SLE were 5.87 (4.89-7.05) for primary Sjögren syndrome, 5.40 (3.37-8.65) for systemic sclerosis, 2.95 (2.04-4.26) for myasthenia gravis, 2.77 (1.45-5.32) for idiopathic inflammatory myositis, 2.66 (2.28-3.11) for rheumatoid arthritis, 2.58 (1.16-5.72) for multiple sclerosis, 1.68 (1.22-2.32) for type 1 diabetes mellitus, 1.39 (0.66-2.91) for inflammatory bowel diseases, and 0.86 (0.43-1.71) for vasculitis.

Conclusions and Relevance  The individual risks of SLE and other autoimmune diseases were increased in families that included patients with SLE. The heritability of SLE was estimated to be 43.9%. These data should be considered when counseling families with affected members.


‘Brain pacemaker’ may slow effects of Alzheimer’s | Watch XFINITY Videos Online | News | Comcast

Watch the ‘Brain pacemaker’ may slow effects of Alzheimer’s. featured XFINITY video online by Comcast


Work Injury Management | Physical Therapy El Paso | Sport and Spine Center


The Potentially Dangerous Intersection of Healthcare and Social Media

Lately, there have been numerous reports in the media raising patient privacy concerns due to healthcare providers’ use of social media in the workplace.  A few examples include:

  • An ER nurse posting to Instagram a photo of a bloodied trauma room taken just after treating a patient who had been hit by a subway train – causing the hospital to take action against the nurse and terminate her employment;
  • A young St. Louis obstetrician who took to Facebook to air complaints about a chronically tardy patient, who had suffered a stillbirth – which was reposted and drew hundreds of angry comments and led to a reprimand of the physician by the hospital where she worked;
  • A Northwestern University physician posting photos of a student admitted to a Chicago hospital for extreme intoxication – leading to a $1 million lawsuit for invasion of privacy and infliction of emotional distress;
  • A Chicago ER nurse sharing information on Twitter about a gunshot patient, including insulting tweets and a photo of the bloodied trauma room where the medical staff tried to save him – leading to a lawsuit against the nurse and the hospital for negligence and emotional distress seeking more than $100,000;
  • Reports of abuse of elderly residents of nursing homes and senior care facilities in California, Colorado and Iowa, including the posting of nude and other humiliating photos to Facebook, Instagram and Shapchat – leading to termination, license suspension, and even criminal prosecution.

These and other examples demonstrate that patients, employers, regulators and even law makers and law enforcement are taking very seriously these new types of privacy concerns spawned by emerging and evolving social media platforms, and they are becoming more aggressive in pursing such cases.  Some employers and industry groups are undertaking efforts to revamp internal policies and procedures and training methods to address issues unique to the ever-changing landscape of social media technology.  There is no way to tell what the future might bring in terms of patient privacy issues and social media, but it seems likely that these challenges will continue to plague the healthcare industry.


Social Media, Value and the Future of Healthcare Communications

While nobody can predict what changes the American Health Care Act will bring, two healthcare trends seem certain to continue under any environment: the move toward more value and outcomes-based care, and health consumers’ growing adoption of digital and social media tools. Though motivated by different forces, I see these trends as deeply intertwined, and predict their continued convergence will have major implications for healthcare communications.

In a fee-for-service environment, everybody is incentivized based on the volume of care they provide. When a previously treated patient returns to the hospital, the hospital gets to perform more services and send a new bill. But increasingly now, doctors and hospitals’ incentives are becoming aligned with the quality of the care and overall population health outcomes. In Medicare ACO arrangements, for example, health systems that cut costs while meeting health benchmarks for their patients get to share in the savings. A patient’s re-admission eats away at profits.

We’re seeing a similar trend in pharma too, where drug companies are experimenting with value-based contracts  with insurers that require them to return money if patients fail to achieve expected results. Pressure on pricing is also shifting attention to outcomes.

For providers and drug makers alike, this new environment means it’s no longer enough to simply market and sell treatments. Our industry must also think holistically about patients. If you sell a drug that a patient forgets to take, or if a patient’s poor health habits erode the benefits of his treatment, outcomes will suffer. Factors like adherence and lifestyle become as central to the equation as sales volume and efficacy.

It’s well established that communication skills and regular contact between provider and patient help improve these outcomes. And that’s where the second trend comes in: the rise of mobile health (mHealth) and healthcare social media. Patients are adopting a stunning new range of interactive tools like medication reminder apps, activity trackers, social media channels and online forums to help themselves manage daily health needs. Much has been written about how these tools are empowering patients to become more active participants in their care. But less appreciated is how these digital and social tools can also bring efficiency and scale to healthcare communications. Patient-doctor relationships were once confined to exam room visits and Sunday newspaper columns. Today’s digital world offers hundreds—if not thousands—of additional touch points.

These tools offer tremendous opportunities to deepen relationships and communication, but also add to the skills clinicians, insurers and pharma companies must master.  

Let’s take a closer look at the new communication priorities required to thrive in the new value landscape.

Understand patient needs

Drug companies convene patient focus groups to test ad campaigns, but this level of examination can be applied to all parts of the patient experience. Social listening is one powerful tool to accomplish this. You’d be surprised at how much detail people share about their conditions in online forums. Through these messages, we can construct intimate portraits of a condition, including what information people seek at different stages of their journeys and the common pitfalls where their adherence gets disrupted.

Engage directly with consumers

Although more and more healthcare industry companies are becoming active on social media channels, few are truly exploring the possibilities of two-way communications. We can improve by asking open-ended questions on Facebook and then listen to the responses. We can look for people seeking help online, then leverage company expertise to provide answers. We can produce live streaming events that use social media to facilitate dialogue that builds relationships and trust.

We can also help by training doctors—the most trusted figures in the health ecosystem—to be more involved with patient communities on social media. The primary care visit offers doctors a face-to-face opportunity to explain the importance of diet and exercise to patients. But imagine how much more adherent patients might be if the doctor could reinforce this message continually throughout the year? Or how we could improve population health if reminders about routine screenings came from intimately trusted authorities. With strategic use of Twitter, Facebook or Snapchat for educational messaging, this becomes easy—and efficient.

Create content that resonates

The Internet is full of factual information that nobody actually reads because they’re too busy devouring misinformation that’s fun to share and click on. But when health outcomes matter, we must compel patients to tune in to health messaging they might otherwise ignore. We can compete in this battle for mindshare by weaving health issues into evocative narratives of real people, or by expressing complicated scientific concepts in relatable everyday terms. Selecting the right spokesperson is another way to capture attention.

Meet people where they are

We already know that well-run patient service programs help people navigate the obstacles of starting a new treatment. The next step is to make sure these programs integrate seamlessly into patients’ lives. For most demographics, this means optimizing for smartphone use. As mobile messaging continues to grow, we should explore chat extensions for nurse navigator hotlines.

Similarly, it’s important to make sure information and programs are available on the platforms our audiences use most. More pharma companies are establishing branded presences on Facebook, the world’s most popular social media platform. And now that scrolling ISI is available in Facebook ads, it is getting easier for pharma to participate.

Don’t shy away from difficult topics

Increasingly, social media is becoming the place where patients go to sound off about concerns with pricing and access. My colleague Meg Alexander, head of Risk & Reputation Management at inVentiv Health Communications, recommends companies be prepared to communicate about the value their medicines deliver to stakeholders who use Twitter or Facebook to raise concerns about affordability.  They must also make out-of-pocket cost assistance information easier to find and simpler to understand. In terms of building relationships, there’s a world of difference between demonstrating you are listening and appearing to dodge difficult questions. Furthermore, patients cite drugs costs as a major factor in nonadherence, so raising the visibility of assistance programs has the potential to affect outcomes.

Don’t Lose Sight of the Human Element

While it’s easy to get excited about new gadgets, remember that the overall goal of mHealth and social media must be to deepen relationships and communication. For example, telemedicine can connect elderly and disabled patients with specialists who would be hard to visit in person. Step counters come with apps that create social communities that encourage participation. Be wary of advances that aim to displace human interaction. The power of these new technologies is realized when there’s a caring, concerned person on each end. A recent study found that simple medication reminder apps did not improve adherence. In contrast, Medisafe, a medication reminder app that alerts family or friends about missed doses, claims 71 percent of users improved adherence after adding its “Medfriend” feature.

As the healthcare system continues its shift towards value-based models, genuine, personal communication will only increase in importance. Where writing a prescription used to be the end of interaction, we should now see it as the beginning of a relationship. Digital and social media tools must be recognized as a standard part of quality care. 

Julian Suchman is a digital strategist at inVentiv Health Communications.


The 5 Biggest Myths About Metabolism

From skipping meals to eating at night, it’s time we separate fact from fiction when it comes to metabolism and weight loss.


A source of confusion for some and a scapegoat for extra weight around the midsection for others, metabolism has long been a topic of hot conversation. Without it, we would lack the energy to get out of bed in the morning, let alone burn calories all day long. However, even with its numerous benefits, metabolism often gets the brunt of the blame with weight gain. With all of the fad diets and special tricks meant to speed up one’s metabolism (hot sauce anyone?), the facts often get blurred with fiction. To help clear up the confusion, we uncovered the truth behind the top five metabolism myths.