- Dr. Leslie Rubin who is accomplished
in so many fields I hardly know where to begin,
but he is professor of pediatrics
at the Morehouse School of Medicine,
and the Southeast Pediatric Environmental
Health Specialty Unit at Emory University,
the medical director of developmental pediatrics specialist
in Atlanta, Georgia,
and president of Innovative Solutions
for Disadvantage and Disability.
We'll hear more about that from Dr. Rubin
later on this afternoon, so Dr. Rubin.
- Thank you, Lucy.
Hello everyone.
Thank you Lucy for inviting me here,
and nice to meet you all.
My task is to look at the pediatric aspects.
The fact is that those of you who deal with children
might have to face.
Right, my disclaimers.
The head of CDC said that never in the history
has there been such a dramatic effect on the fetus
from a mosquito, and I just thought
I'd tell you what thoughts went through my head
is we're dealing with the Zika virus.
Zika virus comes from Africa,
from the Zika Forest in Uganda,
but we've dealt with these African viruses before
with HIV is another one of those viruses
that comes from Africa through primates
and so has Ebola, so we're gonna have viruses come and go,
and they're each gonna pose different problems
for us, different challenges,
and as long as we can tackle them
in the way we are with incredible investment
in labor at CDC, I can tell you
'cause I live in Atlanta,
and all the CDC people I know are not doing
what they were doing before.
They're all like doing CDC stuff,
and the people who are not doing CDC stuff
are doing the stuff the people who are doing,
are doing Zika stuff,
the people who are not doing Zika stuff
were doing the stuff that the people
who were doing other things are doing for Zika,
so crazy, anyway.
Zika is not the only virus,
or the first virus, that we've become aware of
that caused problems in the fetus,
and I just wanted to alert you to
or remind you of the fact that in the 1960s
there was a massive epidemic of rubella.
Now rubella in kids produces a rash,
but rubella in pregnant women
result in major outcomes for the fetus,
and in the mid 60s, there was a massive epidemic
with about 20,000 women who were infected
during their pregnancies, and these resulted
in a condition which is called Congenital Rubella Syndrome.
The kids who were born with the most severe cases
were called, and I hesitate to say this,
but this was the term used,
blueberry muffin baby because they had
these little spots that were petechiae
on their bodies, but the main problem was
it affected the central nervous system, the brain,
and I can tell you because I took care
of many of the kids in the later stage,
and most of their problems
were intellectual disabilities,
seizure disorders, visual and hearing impairment,
but also autism, so that's very ironic
that autism was a part of the clinical spectrum,
so the lessons we learned from then,
these are lessons that are being recapitulated
in the Zika age is that pregnant women
who are infected with these,
even if they have mild infections
can affect the fetus to a significant degree,
and as was mentioned by Kristin before,
the other viruses we're aware of
that can cause similar effects on the fetus
such as toxoplasmosis, citomegalovirus,
herpes, HIV, and now, the other lesson
we learned is that we should give vaccines,
and I put this in the entrance in a dramatic way
because the irony is so many people
are avoiding MMR vaccines
because they say it causes autism,
when the vaccines are preventing conditions
that could potentially cause autism, so there you go.
This is fascinating to me in that the Zika viruses
live and reproduce in other cells.
They're just pieces of DNA or RNA,
and they have to get into cells
in order to replicate, so when they do get into cells,
they have a predilection for certain cells.
Each virus has its own character,
and these Zika virus seem to like neurons
and gets in and just messes things up,
so it messes up mitosis,
and what happens then is not only messes up mitosis,
if it hits the neural stem cells,
and the neural stem cells we know
produce neurons, astrocytes, oligodendrocytes,
and what happens then is because the virus
just destroys the reproductive capability
of the cell, it sort of leads to apoptosis,
and you don't get all these cells,
and if you don't get all the cells,
then you don't get all the differentiation of the cells,
you're gonna have many less cells in the brain,
and that's what happens in Zika infection.
You get less cells, and you get less cells,
you get a smaller brain,
and then hence the micro, which is small,
cephaly which means head,
so it's the small head.
So the Congenital Zika Syndrome
like the Congenital Rubella Syndrome
has certain characteristics,
and it's defined by the fact
that there is some history of infection in the mother,
and at birth, the kids have certain characteristics
which is small head circumference
and often eye pathology.
It's very interesting because one of the first findings,
or reported findings on congenital rubella
was in fact cataracts and uveitis,
so that's not unusual that these viruses
that attack the central nervous system
will affect the eye, but also,
here's a picture, also because it affects the brain,
it affects what the brain does,
and what the brain does is controls function,
motor function, cognitive function, social function,
and so these kids will have limited responses,
abnormal muscle tone, limited limb movements,
joint contractures, they will be neurologically involved.
So what do we need to do
in the initial newborn period?
The most important thing, if you're evaluating the infants,
is obviously to do the typical
newborn neurological examination,
and particularly look at the eye,
and you might need an ophthalmologist do to that,
and then do an auditory brainstem response,
the standard newborn screening is inadequate
according to the CDC, and the thing about this eye problem
is that these two is that it's so similar
to congenital rubella, the eye and the hearing,
so these are neurological impairments
in the sensory system.
The CDC also recommends that blood test be taken,
serological testing for Zika,
and we heard about some of the kind of limitations
on what that will reveal,
but also blood count, metabolic panels,
did it affect the liver, head ultrasound is helpful,
and the MRI if necessary,
so I don't know, I was trying to work out
what the CDC was trying to get at
with consider MRI which is their language,
and I wasn't quite sure,
so I just leave it in there, consider MRI.
In addition, when you see the newborn infant,
you need to say okay, what is going on here,
and what do we need to do?
So what they say is that if the clinical features
are uncomplicated, then you definitely need
to refer for early intervention and for physical therapy,
if necessary, that's for the multi-system.
However, obviously, if there are any complications,
and they list these in this document,
which I recommend for any of you
who want to look at
what the comprehensive recommendations are
over the CDC, it's a wonderful document.
You can get it online, MMWR, from the CDC, August,
and I'm sure there's a newer report,
but this is the comprehensive document.
Anyway, so you refer as necessary,
and they comment on possible joint contractures
because of the muscle spasticity,
and they also comment on because you're having the fact
of the virus affecting brain and brain cells,
you can have some hypothalamic, pituitary dysfunction,
refer to an endocrinologist,
and obviously, if there's a question of diagnosis,
they recommend you consult with a geneticist
or anybody in infectious disease
to tell you whether this is the Zika effect or not,
or Zika is involved.
As far as breastfeeding's concerned,
the statement is that the benefits of breastfeeding
outweigh the risks of Zika,
and both the CDC and WHO strongly recommend
that you continue with breastfeeding regardless,
so there you go.
If there's any concern about breastfeeding.
The nice thing about what the CDC has done as well
is that they address the needs of parents
because you heard Dr. Semin, right,
tell you about the anxiety of parents
and most of the counselings to parents
who are anxious,
and I just cannot imagine for the parents
to have an infant who has such a condition
where you have this kind of long term commitment
to helping the child and whatever the consequences might be,
the uncertainty and the consequences,
and this is the CDC says this is particularly important
for the low-resource families,
the low-income families
because they're already overburdened.
They already have a whole host of pressures
and limitations to their resources.
So they recommend that we use the local, state,
regional resources because they've been built into place
from decades ago from laws that were passed
that include the early intervention programs.
They also recommend that we tell the parents
to look at the CDC website.
There's a specific site for families
who have newborn affected by Zika,
so we can tell the families
to have a look at that site.
In California, you have a wonderful program
called California Early Start,
which will provide services to children
with any children birth to three
who have developmental delays,
developmental disabilities,
and that's the main stand.
I will tell you in Atlanta
when I deal a lot with low-income minority families,
whenever we have any difficulties,
we go straight to our version of this California Early Start
which is called Babies Can't Wait in Georgia,
and they provide in-home counseling,
in-home therapies, and it's not intense, necessarily,
but it's something, and it's helpful,
so I strongly recommend you use that.
And then of course for the long term follow up
for the infants, there's some standard issues,
so standard things you need to do,
routine healthcare measure,
monitor growth and development,
test development at each visit,
refer for therapies and specialty services as necessary,
provide support for families,
establish a medical home.
This medical home concept is a very important one
for kids with disabilities, and in fact,
the medical home concept was developed specifically
for kids with disabilities because of the multiple services
they needed and their families had
for some degree of coordination of care,
and that's the medical home concept,
and ideally, an interdisciplinary team,
if there is one, and I'm sure
that this would be more relevant in areas
where the Zika virus is much more prevalent,
and so it's Texas and Florida so far,
so you know but stay tuned,
and I think the more we're on top of it,
and I think the very fact
that there was such a mobilization
of resources internationally has resulted
in that sort of limitation in the spread of the virus,
so the fact that we're talking about it,
and you might say well I don't know
if I'm ever gonna see anyone with it is good
because hopefully you won't,
and in California, and hopefully,
we've contained it, and it will kinda begin to recede.
The CDC also recommends additional evaluations
for kids who have the diagnosis of congenital Zika,
and that is that comprehensive neurological exam
at age one and two months,
and then as needed after that.
Definitely routine eye exams at three months,
and also hearing, again, assessment
at four to six months.
They also recommend thyroid screen,
and again, because of the hypothalamic pituitary effect
that might take place in the more severe cases.
Also, as mentioned, that there have been some fetal deaths,
and obviously, there's a great range of severity
in the expression depending on when the mother
had the infection, which trimester,
the degree to which she has a viremia,
and so this is another statement made by the CDC
based on a finding where they reported in November
that there were 13 infants born
who had congenital Zika without microcephaly at birth,
but who may have later problems,
and if you bear in mind that with the congenital Zika
you've got the virus, if the infant has the virus,
then the virus is still in the body,
it's in the brain, it's going to affect cells,
so there will be some later consequences,
so even if the infant is born with a, let's say,
average sized head, you do need to follow these infants
according to the criteria of the CDC.
Now, they don't know what the long term outcome is
because it's only been discovered
on the last couple of years,
but I think we can take our lessons again
from the congenital rubella epidemic
where we had developmental delays,
sensory disturbances, visual disturbances,
clinical picture of cerebral palsy.
Also, who knows even the clinical picture of autism
as happened with congenital rubella,
feeding problems with the more severe
oral motor difficulties,
and some behavior challenges,
and these, we have no idea what they might be,
and I think you also had something like this
up in one of your slides,
but I left it in anyway.
It doesn't hurt to repeat some things that are important,
and these are important things.
Also, Zika is a notifiable condition,
that if you do see a case of Zika,
you do need to notify your local health district
or whatever it is,
public health department,
and depending on, regardless of whether the child
had any infection or not,
so if there is any history of Zika, potential Zika,
you do need to notify your health department.
Alright, so in summary, number one,
you need to know about Zika,
and you need to know about Zika in your community,
and even if you don't need to know about it
in your community, and there isn't any Zika,
you need to know about it in the world
because just in case you just need to be aware.
Secondly, if you see an infant who has a small head,
and in your work up you're looking for
any of the other causes, the genetic,
or the intrauterine infections, the ToRCH infections,
or as mentioned, tobacco and alcohol also
result in small head circumference,
you should just bear in mind Zika.
Thirdly, you really need to have a very systematic approach
to these infants because you need to monitor
their development, you need to try to encourage
a more positive development with the therapies
and interventions, and most significantly
from my standpoint is the support of the families
because they have to deal with the realities
as well as the anxiety, so there are realities
and anxieties, and they have to deal with both,
so it's important for us to have that mind,
so that's the support for the families,
and then of course, notify your public health department,
so that's it, and of course,
as Kirsten mentioned, we are still learning.
We're learning all the time,
and it's very helpful if you just keep up
with what's going on,
and it's at the CDC website,
so I thank you for the opportunity to present.
(audience applauding)