The threat of Zika virus is reshaping operations at hospitals across the country, as medical teams rush to figure out how best to provide care for pregnant women with the disease and monitor and treat babies with related brain damage.
With scientists still trying to better understand the virus — and without any treatments available — hospitals have been forced to adapt to a changing Zika outbreak, particularly in states such as Florida, Texas, and New York that are at risk for local transmission or have seen large numbers of travel-related cases.
Hospitals say they have built up their diagnostic tools, started performing more regular ultrasounds for patients, and are keeping closer-than-usual watch on amniotic fluid levels and fetal heart rates. Social workers and physical, speech, and occupational therapists are preparing to work with babies born with Zika-associated defects, should they require their care.
“We don’t really know what to expect fully from Zika at this point,” said Dr. Gary Clark, the chief of neurology at Texas Children’s Hospital in Houston. “We’re trying to prepare ourselves for a virus that seems to infect the nervous system quite prominently in multiple ways.”
The number of babies born with Zika-related defects in US states remains low: only 16, so far, according to the Centers for Disease Control and Prevention. But 510 pregnant women overall have contracted the virus and many of them have yet to deliver their babies.
Scientists still don’t know exactly what percentage of pregnant women infected with Zika will give birth to children with defects.
That unknown, however, is only one of the mysteries of Zika, which is primarily spread by mosquitoes but can also be transmitted through sex. Scientists are still learning not only about the virus and how it passes from mother to fetus, but also about the ways in which it can affect those who contract it.
To bridge the gap, hospital officials say they have assigned doctors to keep up with the growing body of literature and confer with public health agencies. They are also bringing together obstetricians trained in high-risk pregnancies, pediatrician specialists, and virologists and other biomedical researchers.
In Miami — the only city in the continental US to see Zika cases spread by local mosquitoes — pediatricians and obstetrician-gynecologists are working hand-in-hand when caring for pregnant women with Zika, said Dr. Christine Curry, an obstetrician-gynecologist at the University of Miami and Jackson Memorial Hospital.
They review ultrasound results together, coordinate long-term planning with specialists and the mothers-to-be, and alert doctors on call when to expect a birth from a Zika patient.
“When the mom comes for a delivery, the pediatric team has already seen what’s going on,” Curry said. “Usually a pediatrician learns about a kid when they get a page and they come and we hand them a baby.”
Doctors say they don’t have good answers yet to the most pressing questions they get from pregnant patients, including if their fetuses are at risk throughout the pregnancy or only certain stages, and how likely their children are to have some sort of developmental problem.
“That’s a somewhat difficult question to answer right now given what we know about Zika and what we don’t know about Zika,” said Dr. Martha Rac, a maternal-fetal medicine specialist at Texas Children’s Hospital, which has organized a special Zika clinic.
Her colleague, Dr. Catherine Eppes, added: “While we can’t tell people exactly what percentage of the time that happens, it’s not automatic.”
In addition to microcephaly — a condition in which the brain fails to develop fully and the head remains unusually small — doctors have reported other problems with brain formation, vision, cognition, and joints in babies born to Zika-infected mothers. Even when there are physical deformities, ultrasounds cannot always detect them before a woman gives birth.
Doctors also worry about what might happen to children who appear to be fine at birth. In the case of other congenital infections like cytomegalovirus, hearing and vision problems can emerge in apparently healthy children years down the road.
“That may just be the tip of the iceberg,” Dr. Jeanne Sheffield, the director of maternal-fetal medicine at Johns Hopkins Hospital, said about microcephaly. Hopkins has also formed a Zika group as Maryland has notched 57 travel-related Zika cases.
When Zika first started making headlines at the beginning of the year, and the first flood of calls came from patients who had recently traveled to Latin America, many hospitals were not ready with a coordinated response. As the epidemic spread and more travel-related cases appeared in the United States, teams of doctors geared up to handle a continued demand for information and consultations from patients, especially as the summer mosquito season approached.
“We knew we didn’t want to relive what we went through in January,” said Dr. Ashley Roman, director of maternal-fetal medicine at New York University Langone Medical Center, where a multidisciplinary group of experts started meeting weekly in May.
The group outlined how the hospital should respond — what updates it should put on its website, for instance, or how many additional nurses it would need — to a variety of scenarios, including the now-real situation of mosquitoes spreading Zika in Florida. Although New York is at a relatively low risk for local mosquito-borne Zika transmission, it has had more travel-related Zika cases — 530 — than any state in the country.
The CDC, the American Academy of Pediatrics, and March of Dimes are working on guidelines to care for and track babies born to Zika-infected mothers. But the preparations hospitals are going through now are to ensure they are ready to care for additional infants who may have trouble swallowing, suffer from seizures, and require dedicated care from a host of subspecialists.
Children who may be affected by Zika in Florida — which has had 60 pregnant women with Zika infections — will enter the state-run Early Steps program, which provides a range of therapy services and will track their health for several years. Even with the program, doctors there are already discussing how to make sure they can keep tabs on what milestones their patients do and don’t hit as the children get older.
“If you have a baby and the baby looks completely normal, what’s going to drive you to keep coming back?” said Dr. Ivan Gonzalez, a pediatric infectious disease specialist at the University of Miami. “Our challenge is to try to capture them, keep calling them, reminding them.”
The systems hospitals have been putting into place in recent months will guide how they care for Zika patients in future years, but doctors said their experiences with Zika will also inform how they will respond the next time they are called into action against a puzzling disease.
“None of us expected a flavivirus would do this, so we’ve been surprised,” said Dr. Kjersti Aagaard, a maternal-fetal medicine specialist at Texas Children’s Hospital, referring to the virus family Zika is in. “But that probably means this isn’t the first time we’re going to be surprised.”