SAN JUAN, Puerto Rico — Dr. Carmen Zorrilla, an obstetrician-gynecologist who specializes in high-risk pregnancies at San Juan’s University Hospital, meets regularly with pregnant women to explain how to prevent mosquito bites that could carry the Zika virus and so threaten the life and health of their unborn children.

Though Zika poses little danger to most people, researchers have confirmed a link between Zika infections in pregnant women and an unexpected rise in infants born with microcephaly, a serious neurological abnormality that causes infants to be born with unusually small heads, and can damage the brain.

So far, Zorrilla knows of only one University Hospital patient who lost a child to the Zika virus, and the doctor was not at liberty to discuss the details of that case. But more than 168 pregnant women in Puerto Rico have already tested positive for Zika since early June, and the U.S. Centers for Disease Control estimates that a quarter of the island’s population will be infected with the virus by the close of 2016.

With this grim projection in mind, Zorrilla told the Register that “hundreds of children” will be put at risk before the scourge runs its course.

Puerto Rico’s daunting struggle to protect pregnant women from Zika serves as a warning for public-health authorities on the U.S. mainland, where warm-weather states like Florida and Texas could face Zika outbreaks.

As of June 22, the Centers for Disease Control reported 819 travel-associated cases in the U.S., but no locally-contracted cases.

Specialists predict that well-established mosquito-control measures should contain the number of locally-contracted Zika infections, and U.S. residents who are pregnant or planning to have children have been directed to avoid Latin American and Caribbean countries, where Zika has established a foothold.

But Florida and other states have scrambled to prepare for a homegrown outbreak.

A likely scenario is a Florida resident traveling to a high-risk area and returning with a Zika infection. When that individual is then bitten by the Aedes aegypti, the type of mosquito that has transmitted Zika abroad, the virus could be introduced to a local breeding ground.

“All it takes is for one mosquito to bite that individual,” Dr. Carlos Fernandes, the manager of mosquito control in Florida’s Hillsborough County, told Fox News.

Prevention, education and testing are key elements of the CDC’s response to the spread of the virus northward from Brazil and other South-American countries that have seen an increase in birth defects tied to the virus.

As Brazil prepares to hold the 2016 Summer Olympics, growing concern about Zika has prompted a number of athletes, including Irish golfer Rory McIlroy, to announce that they will not compete, and public-health experts have stepped up their campaigns to educate the American public.

“The greatest danger is to the fetus and developing infant in the uterus, where Zika can cause terrible defects of the brain and central nervous system,” Dr. Irwin Redlener, an authority on health policy and management at Columbia University’s Mailman School of Public Health, told the Register.

Specialists have learned more about the Zika virus since the outbreak in Brazil prompted the World Health Organization to declare a public-health “emergency” in February.

“The virus may also have subtle, though lasting, consequences on brain functions and behavior for the growing child [in utero],” explained Redlener, who is a pediatrician.

“Zika virus is definitely transmitted by the bite of the infected mosquito, which is why mosquito control is critical. But it is also clear that Zika can be passed from person to person through unprotected sex.

“Even though scientists do not know how long Zika will remain viable in the body of an infected person, many officials are recommending waiting for a year or more before becoming pregnant, if it can be determined that they have acquired the virus.”

 

CDC Interim Report

In mid-June, the Centers for Disease Control issued a 58-page interim report on the virus that outlined a plan for states and localities to respond to expected outbreaks on U.S. soil. Humid summer weather in Texas, Florida and other Southern states creates an ideal breeding ground for the type of mosquito that carries the virus. But, in contrast to Puerto Rico — where authorities have struggled to implement an effective mosquito-control system, with the insects breeding in abandoned homes and old tires and many low-income residents living in homes without screens or air conditioning — the situation on the ground in the U.S. will make it easier to stop the spread of the virus.

At present, the CDC will focus much of its resources on helping local authorities improve mosquito-control efforts, update blood banks on the developing situation, and encourage the testing of pregnant women in high-risk areas.

Still, while experts do not expect a widespread outbreak of the virus on the mainland, they warn that a relatively low number of infections among pregnant women could still have an outsized impact for the families involved, with abortion offered as one response to the diagnosis of microcephaly.

“Unfortunately, no treatment is currently available for Zika,” noted Redlener. “Some women elect to terminate their pregnancies if testing determines Zika presence. Clearly, this option is not available or acceptable to many women.”

 

Microcephaly Risk

Breaking-news reports that chart the northbound spread of Zika to the U.S. have already stirred great anxiety among pregnant women and couples hoping to start families soon or have more children.

Deacon Timothy Flanigan, an infectious-disease specialist at the Alpert Medical School of Brown University, acknowledged the devastating impact of a birth defect like microcephaly. But Deacon Flanigan also emphasized that the risk of microcephaly appeared to be low, though research is ongoing.

“A woman who has a Zika-positive test should not assume her child will definitely be born with terrible neurological abnormalities, and she should not be coerced into having an abortion,” he said.

“In fact, microcephaly, which is a devastating abnormality in neurological development, appears to be uncommon,” he said, pointing to the findings noted in a recent CDC document, “Update: Interim Guidance for Health Care Providers Caring for Women of Reproductive Age With Possible Zika Virus Exposure — United States, 2016.”

That CDC report referenced the findings of one study of a 2013-2014 Zika virus outbreak in French Polynesia. The researchers “estimated that microcephaly affected approximately 1% of fetuses or infants born to women infected with Zika virus during the first trimester of pregnancy.”

However, a more recent study of infants born to pregnant women infected with the virus in Brazil, suggested the risk of  microcephaly was between 1-13%. And Deacon Flanigan strongly endorsed the CDC’s recommendation that pregnant women in high-risk areas be tested for the virus, and that ultrasound screening be used when exposure to the virus is confirmed.

“The ultrasound screening is important,” he added. “When there is any question of developmental abnormalities, many parents will still have the child and care for that child. But the ultrasound can help them prepare themselves for the kind of care that will be necessary.”

He also noted new information linking the transmission of Zika to sexual contact, leading the CDC to advise individuals who have traveled or live in high-risk areas to use a condom or delay sexual contact, in some cases for up to six months.

“The Zika virus can be passed from a man to a woman through semen,” explained Deacon Flanigan. “If a man has been to a Zika-exposed area, the CDC recommends that he refrain from having unprotected sex, or trying to conceive a baby, for eight weeks.”

“If the man has a clinical illness,” he added, “there is concern about a higher level of infection, and it is recommended that he abstain for six months.”

It is recommended that women delay sexual contact “for eight weeks from travel or illness.”    

 

Church Leaders

The latest research on the danger posed by Zika, along with the public-health guidelines that direct couples to avoid transmitting the virus to the fetus, pose a challenge to Catholic patients’ adherence to Catholic moral doctrine, which prohibits the use of artificial contraception and also rejects recourse to abortion when an unborn child is diagnosed with a birth defect.

“Contraceptives are not a solution,” said Bishop Leonardo Ulrich Steiner, an auxiliary bishop of Brasília, Brazil, in an interview with The New York Times after the World Health Organization confirmed that the Zika outbreak in Brazil was linked to an unexpected number of infants born with microcephaly, and organizations like Planned Parenthood pushed for increased access to birth control and abortion in Latin America.

“There is not a single change in the Church’s position,” emphasized the Brazilian bishop.

After Brazil’s Zika outbreak sparked global headlines, the Philadelphia-based National Catholic Bioethics Center (NCBC) received a flood of inquiries from media outlets, physicians and dioceses seeking a response from Church-affiliated bioethicists. And the center, which consults widely on health-related ethical issues, rejected suggestions that the threat posed by the virus justified a change in Catholic moral doctrine.

“Zika is the most recent and high-profile instance of any number of diseases that might have deleterious effects on the unborn children whose mothers contract it while pregnant,” noted a February 2016 statement issued by the center.

“In no way, however, would it justify a change in the Catholic Church’s consistent teachings on the sacredness and inviolability of human life and the dignity and beauty of the means of transmitting life through marital relations,” according to the statement. “Direct abortion and contraceptive acts are intrinsically immoral and contrary to these great goods, and no circumstances can justify either.”

Echoing the response of several Latin-American bishops faced with similar questions, the NCBC also repudiated efforts to reframe abortion as a “therapeutic” measure.

An abortion will not protect or cure the mother infected with the Zika virus, and “it won’t cure the child with microcephaly,” Marie Hilliard, the NCBC’s director of bioethics and public policy, told the Register.

“It will end the child’s life, and that is eugenics. As soon as we embrace eugenics, everyone is under threat.”

 

Puerto Rican Protocol

In San Juan, Puerto Rico, some pregnant women who are infected with the virus will grapple with these same questions, as ultrasound tests chart the development of their unborn children. The testing will be part of a public-health response that also emphasizes preventing transmission of the virus.

“We are following the Centers for Disease Control recommendations that call for the use of mosquito- repellent brands that are safe to use during pregnancy,” said Dr. Zorrilla, during a telephone interview.

To keep the focus on prevention, she regularly meets with high-risk pregnant women in a group setting, where patients receive public-health updates and misinformation can be corrected quickly.

Recently, she helped to launch a model program that provides mental-health screening and treatment for women suffering from anxiety and depression as they endure months of uncertainty about the health of their unborn children.

Blood tests to identify or rule out the presence of Zika are also strongly recommended.

“We have implemented a strategy of testing every pregnant woman during the first and second trimester, even if they don’t have symptoms,” said Zorrilla.

“If they test positive for Zika, their provider is immediately notified, and we do an ultrasound of every organ” of the unborn child, she explained.

“Depending on the gestational age of the fetus, and if the images [show the unborn child’s] development is normal, the ultrasound is repeated every three to four weeks.”

Zorrilla acknowledged that the testing and ultrasound protocols will provide some patients with evidence that their unborn child could have serious birth defects, and so prompt an “ethical conundrum,” with some choosing abortion.

It will be up to Church leaders to affirm the sanctity of all human life and the dignity of an impaired child, while offering support for families who will need help caring for their child. Thus far, the U.S. Conference of Catholic Bishops has not issued any statements dealing with the Zika crisis, said Norma Montenegro Flynn, assistant director of the bishops’ conference’s media relations, in response to an email query from the Register. However, Catholic hospitals abide by ethical guidelines, approved by the U.S. Catholic bishops, which prohibit direct abortion.

Meanwhile, Zorrilla expects that the vital data collected though blood tests and ultrasound imaging will help public-health experts learn more about a virus that has stirred fear and anxiety across the Western Hemisphere.

“We will learn more,” said Zorrilla, “about who gets infected, when and about the outcomes for infants and mothers.”

 

Joan Frawley Desmond is the Register’s senior editor.