On April 14th, The New York Times posed an important question concerning Zika – “Should they [federal health officials] advise American women to delay pregnancy in areas where the virus is circulating?” We bring this up because we asked the same question in March and on further reflection, have not reached the same conclusion as the New York Times.
To recap, last month, the Centers for Disease Control and Prevention (CDC) recognized Zika virus infection as a cause of microcephaly and other developmental complications in-utero. Though there are still many unknowns, this is the first time in history where an arbovirus appears to be causally linked to severe congenital anomalies and developmental disorders. Clearly, as this epidemic unfolds, women of child-bearing age who are pregnant, may become pregnant or would like to become pregnant and who live in countries where Zika is actively circulating bear the brunt of the risk. In Latin America and the Caribbean several governments have advised women to completely avoid conceiving for varying time periods. With the continued spread of the virus, and an increasing number of imported and sexually transmitted cases, the question now is: should the US be doing the same for women in areas which are at highest risk for Zika importation?
As a Zika vaccine is not expected to be developed in the near future, and US mosquito abatement programs will likely struggle to control Aedes aegypti populations to the point where expecting mothers can be 100% sure that they will not be bitten by an infected mosquito, avoiding pregnancy is the lone guarantee that you will not have a child with Zika-related birth defects. However, as of yet, there are no federal advisories recommending avoiding pregnancy specifically. The reason for this lack of guidance is presented in the Times as a dilemma in which health officials either controversially infringe on women’s rights to reproduce or allow these terrible birth defects to occur when more could have been done. Presenting the information in this way poses a false dichotomy.
If science says that waiting to conceive is in the best interest of the mother and infant, then the CDC and other relevant public health officials should make that (non-binding) recommendation and allow women to make decisions accordingly. We should be providing complete information and possible options so that women can make the best-informed decision with their partner and healthcare provider. Doing so empowers women to make the best decision possible for themselves and their families.
We think it would be most helpful if federal health officials provided clear information, including risks and reasoning, for all affected demographics. What follows are some notional guidance for different risk groups in the United States:
Women who want to or who are trying to become pregnant
In places where we see active transmission, it can be hard to avoid mosquito bites entirely, thus there will be some risk to the fetus if a woman becomes pregnant and is then infected. The only real way to completely avoid this risk is not to become pregnant during an outbreak or when you or your partner has been infected. Women and their partners should be advised to weigh these risks, with their doctor, when deciding whether to conceive during a time and in a place where disease exists. Public health professionals should provide their best current estimates of the risks of getting infected and the risk of the fetus being affected if the mother has the virus to inform these decisions. Additionally, they should provide information regarding the risks of using insecticides containing DEET and how those risks compare to those from Zika.
Women who are pregnant in an area with active Zika transmission should be provided with information about preventive measures, including:
- Limiting time outdoors
- Keeping their homes free of mosquitoes
- Eliminating breeding sites
- Using bug repellant (correctly and effectively)-
- Wearing protective and/or treated clothing
- Using a condom the correct way every time
- Avoiding sexual contact that might increase the risk of getting Zika infection.
For women who become infected, the importance of close coordination and communication with their doctors in order to monitor the health of the fetus should be emphasized. Early recognition and close monitoring will provide women with the best information and of the most choices about their pregnancy.
Parents of young children and babies
There is some question as to whether and to what extent Zika infection can impact newborns, infants and toddlers. Until we know more, there should be advice about how to protect babies and children from being exposed, including advice about breast feeding, insect repellent, protective clothing, and limiting time outdoors.
All women and men
All US citizens should understand all of the measures they can take to avoid getting the virus. This includes limiting time outdoors, keeping their homes free of the mosquitoes, eliminating breeding sites, using bug repellent (correctly and effectively), and wearing protective and/or treated clothing, using a condom the correct way every time, and avoiding risky sexual behaviors.
As we learn more about Zika and its connection to fetal birth defects, the guidance issued by CDC and other public health authorities will continue to be refined. Conveying uncertainties about the risks, and the need for constant reassessment of the situation in the US should also be highlighted in all communication materials. Until we know more about what the risks are and about specific measures that will limit those risks, the best thing for public health officials to do is present all of the relevant information and allow people to make their decisions accordingly.