Rio 2016 and the Zika Virus

Rio 2016 and The Zika Effect
Will Brazil’s current Zika virus epidemic spell disaster for the Rio 2016 Olympic Games?

By Jamil Abdur-Rahman, M.D.
The Twin Doctors Travel Bag
microcephaly

Wednesday, Jan 20, 2016 (The Twin Doctors Travel Bag) — In the interest of full transparency let me open this article with a brief but important tongue in cheek disclaimer. “I my friends am a proud Chicagoan. I am a Chicagoan born and bred and Chicago is where both my home and my heart is”. Now friends let me be clear, when I say to you all that I am a “proud Chicagoan” born and bred, I really do mean that I am a PROUD Chicagoan BORN AND BRED. I mean that I am “That Guy”, that I am “That Chicagoan” that goes into a restaurant and asks for a “Pop” instead of a “Soda”. I also mean that I am “That Guy” that calls every subway train that he encounters, no matter what city that he finds himself in when encountering that subway train, the “L Train”. And I am reasonably certain that I am also “That Guy” who a thorough analysis of his blood would reveal higher than once thought to be humanly possible levels of deep dish pizza sauce (Giordano’s pizza sauce of course) and dill pickle spear metabolic break down products. “Dill pickle spear metabolic break down products” you may ask? Yeah, dill pickle spear metabolic breakdown products, you know the stuff that circulates in your blood after your body has finished digesting a slew of Chicago’s very own dill pickle spears. You know, the same dill pickle spears that you MUST have on a hot dog if that hot dog is to ever be considered a “Real Chicago Hotdog”. Yeah that’s right, I’m “That Guy” who thinks, no, let me rephrase that. Yeah, I’m “That Guy” who knows that if you don’t put dill pickle spears on your hot dogs, well then that you’re just not really eating hot dogs. I mean who doesn’t put dill pickle spears on their hot dogs right? A fool doesn’t put dill pickle spears on their hot, that’s who, a fool.

chicAGO HOTDOG

If you don’t know now you know!!!

 

But forgive me friends as I digress. I will just save my little rant about Chi-Town’s favorite way of eating our beloved chemically processed little wieners for another day. But yes, I am “That Guy”. I am that proud Chicago White Sox loving, Chicago Bears loving, Chicago Blackhawks loving, Chicago Bulls loving guy. I’m that proud Chicagoan born and bred. And so you can only image how thoroughly gob smacked I was. How completely and utterly insulted and despondent I felt after learning that Chicago, my hometown, the Crown Jewel of America’s Breadbasket had been eliminated from contention for the 2016 Summer Olympic Games. Rather than awarding the Olympic Games to The Windy City, the International Olympic Committee in all of their infinite wisdom chose instead to award the 2016 games to Rio de Janeiro, Brazil’s second largest city. Now in all fairness Rio is a world-class city in every sense of the word. It is a global treasure that is worthy in its own right of the honor of hosting the Summer Olympic Games. And so while I would have loved to have seen the 2016 Olympic Games being held in my Sweet Home Chicago, I hold no ill will towards Rio de Janeiro. In fact at one point I even gave serious consideration to going to Brazil for the 2016 Games. And so while I presented my little “Proud Chicagoan disclaimer” in a very tongue in cheek sort of way, I do think that it is important to take a serious, fair, balanced and unbiased look now at the 2016 Olympic Games in Brazil and to ask two simple questions. Firstly, will Brazil’s current Zika virus epidemic spell disaster for Rio’s 2016 Olympic Games? And secondly, whether or not the Zika virus epidemic does ultimately spell disaster for the 2016 Rio games or not, should it?

I imagine that by now just about everyone has heard of the Zika virus and of “Zika Fever”, the illness caused by infection with the Zika virus. And while with all of this recent discussion about the Zika virus and about Zika Fever it may feel to most like the virus and the resulting illness caused by infection with the virus is a relatively new phenomena, it in all actually is far from new. In fact, the first known animal cases of Zika Fever were documented in Ugandan Rhesus monkeys more than 60 years ago. These first animal cases of Zika Fever were then followed two years later by the first recognized human cases of Zikia Fever. These first human cases were documented in Nigeria in the year 1954. For the next 50+ years after these first documented human cases were seen in Nigeria all subsequently documented  cases of Zika Fever were observed solely in people living in equatorial African and Asian nations. For reasons still unclear however this rather limited distribution of the virus to African and Asian nations located in the vicinity of the Equator was disrupted in the year 2007 when the first case of Zika Fever seen in a country outside of equatorial Africa and Asia was documented in a person living in Micronesia. After this groundbreaking Micronesian case of Zika Fever the Zika virus then continued to migrate, moving on an eastward tract from the South Pacific towards the Americas before it finally made landfall in both Central and South America. Once in Central and South America the Zika virus, almost as if it had been emboldened by its most unlikely journey much in the same way that a toddler might be emboldened after taking his or her first few successful steps unassisted, it continued to move and to migrate through several Central and South American countries, infecting the inhabitance of these countries with increasing regularity, speed and precision. And as a result today we now have a virtual Central and South American Zika virus pandemic on our hands. In fact at last count when including Equatorial African and Asian nations along with the relatively newly involved Central and South American Nations, the U.S. Centers for Disease Control reported that Zika Fever infections had been documented in 49 countries around the world. Of the 49 countries with documented Zika virus infections it is Brazil that has had the highest number of reported cases. And there in lies the concern for Brazil and for the 2016 Olympic Games in Rio.

mosquito   It is estimated that to date no fewer than 1.5 million Brazilians have been infected with the Zika virus. Unfortunately, many global public health officials only expect that that number will continue to grow in the coming months. That is of course not good news for the nation of Brazil. Nor is it good news for the organizers of Rio 2016. To understand why, consider this. The Zika virus is a blood born virus and it is transmitted from person to person by the simple bite of a mosquito. A full 80% of people who are infected by the Zika virus will never actually go on to develop Zika Fever, the illness that results from infection with the Zika virus. And so after contracting the Zika virus these unwitting asymptomatic carriers will never actually know that they are or were at one point actively infected with and potentially harboring the Zika virus. Additionally, of the remaining 20% of people who after being exposed to the Zika virus will actually go on to develop Zika Fever, most of them in developing Zika Fever will only go on to experience a very generic set of “viral-type symptoms”. These generic “viral-type symptoms” are basically viral symptoms that in their homogenous universality mimic the viral symptoms of many more common simultaneously less problematic viral infections like the common cold or the flu. So basically sufferers of Zika Fever may frequently experience fevers, achy muscles and joints, rashes and conjunctivitis (reddening of the eyes). With the development of these symptoms many Zika Fever sufferers may well know that they have  or at one time had “something”, but they are not likely to know that that “something” is or was Zika Fever. So basically because the vast majority of people who are infected with the Zika virus  (i.e. 80%) will never go on to develop Zika Fever and because the remaining minority of people who are infected with the virus (i.e. 20%) and then do go on to develop Zika Fever will only experience the universally generic and homogenous “viral-type symptoms” of Zika Fever, virtually all Zika virus infected people (asymptomatic and symptomatic alike) will be unaware of the fact that they are (or were) carrying the Zika virus. They will also therefore be unaware of the fact that they are (or may have been at one time) in a sense contagious. The contagion that can result from this innocent lack of awareness on the part of those infected by the Zika virus can be potentially quite devastating for the 2016 Rio Olympic Games.

Why might the innocent lack of awareness on the part of those infected by the Zika virus be potentially devastating for the 2016 Rio Olympic Games? Because after someone has been infected with the Zika virus, be it that they then go on to develop Zika Fever or not, there is typically a 3-12 day incubation period during which that newly infected person is contagious. Now they are not contagious in the sense that they can directly transmit the virus from one person to another person by simply being around that person, but they are contagious in the sense that they will have levels of the Zika virus in their blood that are high enough that should they be bitten by a mosquito that that mosquito will then become a vector that can carry that virus and then transmit it to others by subsequently biting them. Now this presents a big problem because people with the Zika virus are generally not motivated to quarantine themselves during the virus’ 3-12 day incubation period because as we’ve already established, they will either be among the asymptomatic 80% of people that never will know that they are or were carrying the virus or they will be among the symptomatic 20% of people that will likely never know that their generically homogenous “viral-type symptoms” were the result of having had Zika Fever. And so come August 5th 2016 when the Rio Summer Games roll around, it is all together probable that visitors to Brazil will arrive for the games to find themselves in a country where they are surround by lots and lots of people (and mosquitos) that are unknowingly carrying the Zika virus. Of these visitor many of them will then go on to become infected with the Zika virus themselves. 80% of them will of course never know that they are or were infected by the Zika virus while 20% of these visitors will only know that they have or had “some viral something” while they were in Brazil. But many if not all of this 20% will be unaware of the fact that that “viral something” was or is Zika Fever.

airport    Most of these new symptomatic and asymptomatic Zika virus carrying visitors to Brazil will then likely leave Brazil during the virus’ initial 3-12 day incubation window. This will mean that these infected visitors to Brazil will then return to their home countries and that they will be returning to their home countries during the summer months when mosquitos are typically out and about and in search of food. And so these infected returning travelers from Brazil will potentially be retuning to their home countries carrying significantly high enough levels of the Zika virus in their bodies. Levels that will result in any mosquito that bites them becoming an immediate carrier of the virus. And with these circumstances the Zika virus will quite probably then be in Europe, or in the Middle East, or in North America, or in African and Asian nations that previously had never before seen the virus. And just as has happened in countries where the Zika virus is currently endemic, many people in these parts of the world that were previously unexposed will likely then too become infected with the Zika virus. And the virus will likely then continue to infect people in these newly involved parts of the world until such time as (in the countries with more temperate climates) the weather gets cool enough that the virus carrying vector mosquitos die off.

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Courtesy of the CDC

Why do we care anyway about the Zika virus and why could the Zika virus and Zika Fever become a problem for Rio 2016? Well in short while infection with the Zika virus does very little if anything of consequence to healthy men, women and children who are infected by the virus, in developing fetuses who are exposed to the virus as a result of the women carrying them becoming infected with it, be that pregnant women ultimately symptomatic with Zika Fever or not, the consequences of exposure to the virus can be utterly and absolutely devastating. When a pregnant women becomes infected with the Zika virus, the virus upon entering her blood stream travels to the placenta. Being small enough in size the Zika virus upon reaching the placenta is then able to seamlessly cross the placental barrier and to enter the baby’s bloodstream. Once in the baby’s bloodstream the Zika virus travels next to the newly infected baby’s brain where it infects the brain cells. Once a developing baby’s brain cells have become infected with the Zika virus the resulting damage to the brain cells basically causes them to stop growing properly. Because developing baby’s skulls are signaled in-utero to grow only when the brain contained within those skulls is also growing, when a Zika virus infected brain stops growing properly so too does the skull that surrounds that Zika virus infected brain stop growing properly as well. This results in the Zika infected babies having unusually small brains and skulls, a condition that is called “Microcephaly”. Microcephalic babies, in addition to having abnormally small brains and skulls also typically present with a wide range of physical and developmental disorders and delays. Because of the brain damage suffered during the Zika virus infection, babies with microcephaly resulting from a Zika virus infection are frequently plagued by recalcitrant epileptic seizures. Microcephalic babies and children also frequently have difficulties with swallowing, feeding and speech. And as they get older they typically also experience difficulties with maintaining their balance and with walking. What is more most microcephalics also suffer from profound and deeply rooted intellectual delay. As such many microcephalics frequently require intensive and often times expensive lifetime care.

Currently there is no vaccine to prevent a Zika virus infection. There is also currently no effective treatment for Zika virus infections. That of course is unfortunate given that in a country like Brazil, a nation that has had the largest number of Zika virus infections documented over the last year, there has also been an 18-fold increase in the number of babies being born with Zika virus related microcephaly. Now it doesn’t take a Rocket Scientist to realize that that astronomically high figure represents a really big public health problem. In fact th public health “problem” represented by this figure has in reality now become less of a problem and more of a crisis. And it has become a crisis so daunting to the government of Brazil that the government of Brazil has gone so far as to advise all reproductive age women in the country to delay getting pregnant until such time as the Brazilian government, with the support of local and international public health officials, can better devise a strategy to address the current Zika crisis.

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So while the Brazilian government has advised all Brazilian women to put off child bearing until such time as the Zika virus crisis can be better contained, the U.S. Centers for Disease Control (i.e. the CDC) has recently advised all pregnant women from the U.S. to avoid travelling to countries where the Zika virus is prevalent. Listed among these countries in the CDC’s travel alert were Colombia, French Guiana, Paraguay, Suriname, Venezuela, El Salvador, Guatemala, Honduras, Panama and the U.S. territory of Puerto Rico. But ultimately given just how easily the Zika virus can be acquired by anyone (not just pregnant women) travelling to these endemic areas and given also just how easily the Zika virus can then be spread by these non-pregnant returning travelers to both their pregnant and non-pregnant fellow countrymen and countrywomen alike (especially in the warm summer months when mosquitos abound), it begs the question of whether or not simply advising pregnant women to avoid traveling to Zika virus stricken areas will be enough to prevent the virus’ global spread? Or will it ultimately also become necessary for the governments of non-endemic nations to go further that just advising pregnant travelers against travel to areas where the Zika virus is prevalent? Will it become necessary for these governments to also issue additional travel warnings or even to institute strict travel restrictions that will limit all non-essential travel to Zika virus affected countries like Brazil in a concerted effort to prevent a full-fledged Zika virus outbreak beyond the virus’ current pandemic zone? Given how severely Brazil has been affected by the Zika virus and given also when the Rio “SUMMER” games will be being played (i.e. during the height of mosquito season not only in Brazil but also in many other nations abroad), I ultimately think that additional travel warnings or even travel restrictions might ultimately become something that foreign governments will need to seriously consider. Now whether or not western governments sympathetic to Brazil, to its plight and to the absolutely horrendous financial toll that such measures might take on the Brazilian economy would actually issue such warnings or restrictions is certainly another question entirely. But I for one will not be going to Brazil for the 2016 Olympic Games. What’s more I as an Obstetrician will also most certainly be on the lookout for Zika Fever come this summer and fall in the Chicagoland area. And I will be hoping that I not only will not be seeing any cases of Zika Fever in the coming months this year, but that I also will not be seeing a dramatic increase in the number of babies being born with microephaly here in the United States over the 9 to 12 months after the games. Because in reality if there is a Zika virus epidemic here in the U.S. (or anywhere elsewhere for that matter) that results from large numbers of people travelling from the U.S. to the Olympic Games, then the existences of that epidemic may not actually become clear until the following spring and summer (i.e. 2017), a year after the 2016 Rio Summer Olympic Games, when a new generation of Zika virus related microcephalics are being born in America. As I said before I won’t be travelling to Brazil for the 2016 Games. But this “Proud Born and Bred Chicagoan” will be praying for Brazil, for the success of the Rio 2016 Games and for all of those who either travel themselves to the games or who encounter those who travelled to the games upon.