PIRACICABA, Brazil — The dozen patients wait in rows of chairs in the health clinic, while the mosquitoes flit in the shadows, in a city where the Zika virus has just arrived.
Débora Duraes, a nurse at the Programa de Saude da Familia clinic, sees pregnant women everyday. They tell her how much they worry about Zika, the mosquito-borne virus that causes birth defects, and she understands completely. She herself is eight months along, and “for sure” scared of a fateful bite.
This sleepy neighborhood, where Brazil is trying out genetically modified mosquitoes to battle wild ones, offers all the comforts of home to the flying disease-carriers. Windows in houses lack screens, cracked sidewalks hold puddles, and upright old tires filled with water advertise auto body shops. In a nearby neighborhood, the Brazilian Army recently held a “fighting day” spent spraying for mosquitoes and cleaning out mosquito-friendly puddles. Health officials in this 500,000-person city have confirmed 2 cases of Zika in pregnant women, and are investigating another 47 cases, 14 in pregnant women.
Duraes doesn’t live in a neighborhood protected by genetically altered mosquitoes. Bug sprays and mosquito nets are her only defenses at home. “I would like to live here,” inside the clinic, she said.
In Brazil, the nation at the center of the spreading Zika outbreak, millions of pregnant women are panicking over Zika-linked birth defects, now officially declared a global health emergency. Warnings of microcephaly — a shrunken skull and brain seen in newborns in northeastern Brazil after Zika infections — are on TV, the radio, and posters nationwide. On Friday, a study of Zika-infected pregnant women in Rio de Janeiro reported that 29% passed on severe birth defects or had stillbirths, most commonly when infected in the first trimester.
“Patients are showing more concern about Zika virus now than any other serious disease,” obstetrician Viviane Cisi Peliello of the Hospital Santa Joana in nearby São Paulo, a city of more than 11 million people, told BuzzFeed News by email.
And now this fear is spreading north, nine months behind the outbreak. On Friday, Colombian health officials announced the country’s first reports of birth defects — two cases of brain abnormality and one case of microcephaly — linked to Zika infections during pregnancy.
Many more microcephaly cases are likely to appear outside of Brazil, PAHO’s Marcos Espinal said at a Wednesday briefing, “in the next few months.”
That worries Claudio Maierovitch, director of disease surveillance at Brazil’s health ministry. “It started out fast in northeastern Brazil, then it grew slowly. But it could expand in new regions fast like it did before,” he told BuzzFeed News, in Portuguese.
Maria do Carmo Tunussi, a health agent at Duraes’ clinic in Piracicaba, remembers last year’s outbreak of dengue, another tropical virus carried by mosquitoes. At the height of that outbreak, their small clinic saw five or six infected patients a day.
“It was very bad,” Tunussi told BuzzFeed News, in Portuguese. Patients filled the clinic’s now-sparse waiting room, and São Paulo state suffered the highest dengue infection rate in Brazil. Now the worry is that Zika, carried by the same species of mosquito, will follow the same course.
Unfortunately, there isn’t a lot that doctors can do for their anxious pregnant patients. “What worries me the most in this situation is that we have no absolute certainty that the recommendations we are giving to pregnant women related to Zika virus will actually protect them,” said Peliello, the obstetrician in São Paulo.
Although the evidence linking Zika to microcephaly, a shrunken skull and brain, is “extremely strong,” as Lyle Petersen of the U.S. CDC said on Wednesday, it is not yet definitive. Of the 4,222 suspected cases of microcephaly in Brazil, just 641 have been confirmed in cases possibly linked to Zika. The virus has been found in the brains of only a handful of stillborn fetuses and babies with microcephaly.
The disease is presenting public officials with all kinds of scary firsts: It’s the first mosquito-borne disease linked to birth defects, and the first found to spread sexually. It’s also the first infectious disease since rubella, 50 years ago, discovered to cause birth defects. “We haven't seen anything like this before,” Petersen said.
Doctors can’t answer pregnant women’s most common questions. How often does an infection during pregnancy lead to birth defects? Do asymptomatic cases cause birth defects? Which other mosquitoes can transmit the disease? How does the virus infect fetal brain cells? Will healthy children born to infected women later have mental health problems?
We are in a completely new situation,” Peliello said. “We are not used to saying ‘we do not know yet’.”
Experts also don’t know how long the virus persists in semen after an infection. So CDC recommends men who have traveled to Zika-infected regions wear condoms for the duration of a female partner’s pregnancy, just to be safe.
The governments of El Salvador, Brazil, and Jamaica have all recommended that women avoid getting pregnant in the next six months to two years. And the CDC recommends that pregnant women avoid travel to some 34 countries and regions, including Brazil, Puerto Rico, and the U.S. Virgin Islands. But for pregnant women who live in Brazil, that isn’t an option.
“Pregnant women are almost forgotten. All the advice is to not get pregnant,” Priscilla Fillipos of São Paulo, who is 18 weeks pregnant, told BuzzFeed News.
Since Zika seems to infect around 80% of its victims without causing any symptoms, she said, “every pregnant woman is worried here all the time.”
On Wednesday, the World Health Organization unveiled interim recommendations for pregnant women living in Zika-infected regions, calling for ultrasound testing and amniocentesis testing if any abnormalities are spotted, although the sensitivity of the latter test for the virus is “uncertain.”
Poor pregnant women are most at risk, Peter Hotez of the Baylor College of Medicine in Houston testified at a Congressional hearing on Wednesday.
“We’ll soon see Zika affecting all of the poor cities of Central America, Guatemala City, Tegucigalpa, San Salvador, and Managua,” Hotez said. And the same mosquitoes known to carry the Zika virus range across the southern U.S. from Texas to Florida.
“I think the likelihood is high that we might see evidence for Zika transmission in Houston and elsewhere on the Gulf Coast, especially in poor urban areas of New Orleans, Mobile, Tampa, and Miami," he said.
Just 153 cases have been reported in the U.S. (all spread by people who had been traveling). But American pregnant women are certainly worried. U.S. doctors are being flooded with questions and requests for screening from pregnant women who have traveled to regions with the Zika-carrying mosquitoes. A recent report from the CDC investigating 14 U.S. women infected via sex with male partners has added to concerns.
“There has been a major uptick. We are fielding screening requests from a lot more women,” high-risk pregnancy specialist Neil Silverman of the Center For Fetal Medicine and Women’s Ultrasound in Los Angeles told BuzzFeed News.
That Zika infections don’t trigger symptoms in most cases only fuels the anxiety, Silverman added. A CDC report in February that looked at pregnant U.S. travelers said the agency started with screening requests from 259 recently returned travelers. Of those, 151 reported that they had Zika symptoms, such as fever, rash or joint pain, during their trips. Only nine turned out to have Zika infections. But of these, two had miscarriages, two had abortions, and one gave birth to a baby with microcephaly.
Bruno Romani contributed reporting and translation to this story.
Dr. Viviane Peliello works at the Hospital Santa Joana in São Paulo, not the Hospital Geral de Pedreira.