| Title:
|
Epidemic preparedness: Prenatal Zika virus screening during the next epidemic |
| Abstract:
|
Zika virus (ZIKV) is a vectorborne infectious agent of global public health significance due to its potential to cause severe teratogenic outcomes. The question of whether health systems should consider adopting screening programmes for ZIKV infections during pregnancy warrants consideration. In this analysis we apply the Wilson-Jungner framework to appraise the potential utility of a prenatal ZIKV screening programme outline potential screening strategies within the case-finding pathway and consider other epidemiological factors that may influence the planning of such a screening programme. Our evaluation of a potential prenatal ZIKV screening programme highlights factors affirming its usefulness including the importance of Congenital Zika Syndrome as a public health problem and the existence of analogous congenital prenatal screening programmes for STORCH agents (syphilis toxoplasmosis others (eg human immunodeficiency virus varicella-zoster virus parvovirus B19) rubella cytomegalovirus and herpes simplex virus). However our assessment also reveals key barriers to implementation such as the need for more accurate diagnostic tests effective antiviral treatments increased social service capacity and surveillance. Given that the reemergence of ZIKV is likely we provide a guiding framework for policymakers and public health leaders that can be further elaborated and adapted to different contexts in order to reduce the burden of adverse ZIKV-related birth outcomes during future outbreaks. |
| Published:
|
2021-06-11 |
| Journal:
|
BMJ Glob Health |
| DOI:
|
10.1136/bmjgh-2021-005332 |
| DOI_URL:
|
http://doi.org/10.1136/bmjgh-2021-005332 |
| Author Name:
|
Qiao Luxi |
| Author link:
|
https://covid19-data.nist.gov/pid/rest/local/author/qiao_luxi |
| Author Name:
|
Martelli Celina M Turchi |
| Author link:
|
https://covid19-data.nist.gov/pid/rest/local/author/martelli_celina_m_turchi |
| Author Name:
|
Raja Amber I |
| Author link:
|
https://covid19-data.nist.gov/pid/rest/local/author/raja_amber_i |
| Author Name:
|
Sanchez Clemente Nuria |
| Author link:
|
https://covid19-data.nist.gov/pid/rest/local/author/sanchez_clemente_nuria |
| Author Name:
|
de Arajo Thalia Velho Barreto |
| Author link:
|
https://covid19-data.nist.gov/pid/rest/local/author/de_arajo_thalia_velho_barreto |
| Author Name:
|
Ximenes Ricardo Arraes de Alencar |
| Author link:
|
https://covid19-data.nist.gov/pid/rest/local/author/ximenes_ricardo_arraes_de_alencar |
| Author Name:
|
Miranda Filho Demcrito de Barros |
| Author link:
|
https://covid19-data.nist.gov/pid/rest/local/author/miranda_filho_demcrito_de_barros |
| Author Name:
|
Ramond Anna |
| Author link:
|
https://covid19-data.nist.gov/pid/rest/local/author/ramond_anna |
| Author Name:
|
Brickley Elizabeth B |
| Author link:
|
https://covid19-data.nist.gov/pid/rest/local/author/brickley_elizabeth_b |
| sha:
|
530428639c37d5bdc3e89f086505874f0be89427 |
| license:
|
cc-by |
| license_url:
|
https://creativecommons.org/licenses/by/4.0/ |
| source_x:
|
PMC |
| source_x_url:
|
https://www.ncbi.nlm.nih.gov/pubmed/ |
| pubmed_id:
|
34117012 |
| pubmed_id_url:
|
https://www.ncbi.nlm.nih.gov/pubmed/34117012 |
| pmcid:
|
PMC8202108 |
| pmcid_url:
|
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202108 |
| url:
|
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202108/ |
| has_full_text:
|
TRUE |
| Keywords Extracted from Text Content:
|
Zika
human immunodeficiency virus
STORCH
varicella-zoster virus
parvovirus B19
cytomegalovirus
Wilson-Jungner
Zika virus
herpes simplex virus
rubella
amniotic fluid
Children
STORCH
children
travellers
≥7
Zika Virus
fetal
cytomegalovirus
Wilson-Jungner
Brazil, 55 will
immunoglobulin M
Americas
Salvador, Brazil
pregnant persons
fetuses
plasma
newborns
cranial ultrasound
varicella-zoster virus
parvovirus B19
France
ZIKV-specific
humans
serum
brain
SARS-CoV-2
blood
Consortiun
GA
mother
head growth)
individuals
placenta
infants
trimester
femur
Zika virus
herpes simplex virus
NS1
rubella
patients
fetus
Zika
head circumference
IgM
SCREENING PROGRAMME
South-East Asia
urine
DENV
flaviviruses
Dados e Conhecimentos para Saúde |
| Extracted Text Content in Record:
|
First 5000 Characters:Zika virus (ZIKV) is a vectorborne infectious agent of global public health significance due to its potential to cause severe teratogenic outcomes. The question of whether health systems should consider adopting screening programmes for ZIKV infections during pregnancy warrants consideration. In this analysis, we apply the Wilson-Jungner framework to appraise the potential utility of a prenatal ZIKV screening programme, outline potential screening strategies within the case-finding pathway, and consider other epidemiological factors that may influence the planning of such a screening programme. Our evaluation of a potential prenatal ZIKV screening programme highlights factors affirming its usefulness, including the importance of Congenital Zika Syndrome as a public health problem and the existence of analogous congenital prenatal screening programmes for STORCH agents (syphilis, toxoplasmosis, others (eg, human immunodeficiency virus, varicella-zoster virus, parvovirus B19), rubella, cytomegalovirus, and herpes simplex virus). However, our assessment also reveals key barriers to implementation, such as the need for more accurate diagnostic tests, effective antiviral treatments, increased social service capacity, and surveillance. Given that the reemergence of ZIKV is likely, we provide a guiding framework for policymakers and public health leaders that can be further elaborated and adapted to different contexts in order to reduce the burden of adverse ZIKV-related birth outcomes during future outbreaks.
Screening programmes are a core public health service and can be a valuable tool in improving a population's health outcomes. 1 The purpose of screening is to identify individuals in a 'healthy' population who are at higher risk of a specific health condition, in order to provide early treatment and/or intervention to high-risk individuals and thereby reduce the incidence of and/or mortality due to the condition in the full population. 1 Prenatal screening programmes for congenital conditions, including those caused by infectious diseases like Zika virus (ZIKV), aim for the early detection of risk factors for fetal anomalies in order to enable expectant parents to make informed choices about their pregnancy and aftercare. 1 Similar to other STORCH (syphilis, toxoplasmosis, others [eg, HIV, varicella-zoster virus, parvovirus B19], rubella, cytomegalovirus and herpes simplex virus) agents, ZIKV can be vertically transmitted across the placenta during pregnancy with potentially Summary box ► While it is well established that Zika virus (ZIKV) infections during pregnancy can have deleterious impacts on the health and well-being of congenitally infected offspring and their families, the question of whether prenatal screening for ZIKV may be warranted during epidemics remains open. ► Our analysis of a potential prenatal ZIKV screening programme using the Wilson-Jungner framework highlights factors affirming the utility of screening, such as the importance of Congenital Zika Syndrome as a public health problem, a growing understanding of the natural history of the disease, and the likely acceptability of a programme. ► However, our assessment also reveals key barriers to implementation, especially related to diagnostics, antiviral treatments, social service capacity, and surveillance. ► Adopting prenatal screening for ZIKV during an epidemic would enable pregnant persons to make more informed decisions about their pregnancy and facilitate the early identification of exposed newborns for specialised follow-up care, which may be of particular importance for children who present asymptomatically at birth but develop ZIKV-related sequelae in later childhood. ► Nevertheless, to be most impactful, prenatal screening programmes require cheaper and more precise ZIKV screening tests, as well as continued investment in the development of efficacious and safe therapeutics.
deleterious consequences for fetal development. Unlike other STORCH agents, ZIKV is vectorborne, and its transmission by competent Aedes spp. mosquitoes 2 can facilitate explosive outbreaks with spatial and temporal clustering of neonates born with Congenital Zika Syndrome (CZS). [3] [4] [5] As of July 2019, a total of 87 countries and territories across Africa, the Americas, South-East Asia and the Western Pacific reported evidence of autochthonous mosquitoborne transmission of ZIKV, while an additional 61 countries and territories have demonstrated evidence of established Aedes spp. vectors without yet having documented ZIKV transmission. 6 Given the severity of outcomes associated with congenital ZIKV infection and the threat of ZIKV reemergence in areas with prior outbreaks or emergence in new settings, 7 the adoption of a screening programme for ZIKV infections during pregnancy warrants consideration. Here, we draw on the Wilson and Jungner evaluative framework 8 to analyse the feasibility and appropriateness of a prenatal screening programme during a |
| Keywords Extracted from PMC Text:
|
Zika
France
Group53
infection46
plasma
Brazil),64
ZIKV-specific
DENV
transmission.6
trimester.32
injuries.61
fetal
antenatal
Cohorts Consortium,52
antipyretics.34
microcephaly.42
's
SARS-CoV-2
herpes simplex virus
children
Dados e Conhecimentos para Saúde
head circumference
mother
cranial ultrasound
individuals
Children
Zika Virus
missed.28
trimester
patients
adopted.40
STORCH
amniotic fluid
rubella
aftercare.1
serum
performance.38
humans27
age.46
outcomes.37
parvovirus B19
infections,28
CZS.47
mosquitoes2
cytomegalovirus
onset.14
flaviviruses
fetuses
Zika virus
NS1
≥7
framework8
South-East Asia
head growth)46
fetus
brain
CZS.9–11
population,16
accepted.30 31 A
blood
Salvador,
Brazil,55
travellers
infections.15
placenta
's health outcomes.1
Americas
femur
infants
harms.1
urine
pregnant persons challenging.15
transmission.48
pregnancy.49
varicella-zoster virus |
| Extracted PMC Text Content in Record:
|
First 5000 Characters:Screening programmes are a core public health service and can be a valuable tool in improving a population's health outcomes.1 The purpose of screening is to identify individuals in a 'healthy' population who are at higher risk of a specific health condition, in order to provide early treatment and/or intervention to high-risk individuals and thereby reduce the incidence of and/or mortality due to the condition in the full population.1 Prenatal screening programmes for congenital conditions, including those caused by infectious diseases like Zika virus (ZIKV), aim for the early detection of risk factors for fetal anomalies in order to enable expectant parents to make informed choices about their pregnancy and aftercare.1
Similar to other STORCH (syphilis, toxoplasmosis, others [eg, HIV, varicella-zoster virus, parvovirus B19], rubella, cytomegalovirus and herpes simplex virus) agents, ZIKV can be vertically transmitted across the placenta during pregnancy with potentially deleterious consequences for fetal development. Unlike other STORCH agents, ZIKV is vectorborne, and its transmission by competent Aedes spp. mosquitoes2 can facilitate explosive outbreaks with spatial and temporal clustering of neonates born with Congenital Zika Syndrome (CZS).3–5 As of July 2019, a total of 87 countries and territories across Africa, the Americas, South-East Asia and the Western Pacific reported evidence of autochthonous mosquitoborne transmission of ZIKV, while an additional 61 countries and territories have demonstrated evidence of established Aedes spp. vectors without yet having documented ZIKV transmission.6
Given the severity of outcomes associated with congenital ZIKV infection and the threat of ZIKV reemergence in areas with prior outbreaks or emergence in new settings,7 the adoption of a screening programme for ZIKV infections during pregnancy warrants consideration. Here, we draw on the Wilson and Jungner evaluative framework8 to analyse the feasibility and appropriateness of a prenatal screening programme during a ZIKV epidemic (summarised in table 1).
Whereas maternal ZIKV infections are generally mild and self-limiting, a subset of congenital ZIKV infections may disrupt fetal development and result in structural malformations and functional neurodevelopmental impairments, which are collectively recognised as CZS.9–11 Although there is a wide spectrum of CZS severity, children with more severe cases of CZS are likely to have long-term needs for caregiving, medication and specialised support, which can incur substantial social and economic costs for affected individuals, their families and wider society.12 Additionally, evidence from a nationwide retrospective study linking routinely collected data in Brazil from 2015 to 2017 reported a case fatality rate of 9.4% (95% CI: 8.4% to 10.6%) among children with confirmed CZS diagnoses, with more than 90% of deaths occurring in infancy.13
ZIKV infections during pregnancy are primarily identified using nucleic acid amplification and serological tests. Nucleic acid amplification tests detect the presence of ZIKV RNA (ie, indicating acute infection) by reverse transcription-polymerase chain reaction (RT-PCR) in maternal whole blood, serum, plasma, urine and amniotic fluid in patients presenting, in general, <7 days from onset of symptoms, and serological tests detect binding and neutralising antibodies (ie, indicating acute or prior infection) against specific ZIKV antigens (eg, NS1) in whole blood, serum and plasma in patients presenting ≥7 days from symptom onset.14 Ideally, a combination of the high specificity of molecular testing and the high sensitivity of serological testing for ZIKV would potentially allow for the most accurate identification of infections.15 While individual assay performances are highly variable and can depend on the type and timing of sample collected and, in the case of serological assays, the immunological cross-reactivity with other flaviviruses (eg, dengue virus (DENV)), the overall performances of ZIKV-specific assays are largely similar to the performances of routine diagnostic tests for other STORCH agents during pregnancy.16 Integrating ZIKV into the STORCH screening paradigm has the potential to improve standardisation and the differential diagnosis of other congenital infections.
The generally mild clinical presentation and the co-circulation of other immunologically cross-reactive flaviviruses in ZIKV-endemic areas has made establishing a case definition for ZIKV infection in pregnant persons challenging.15 A series of population-based prospective cohort studies (table 2) provide evidence that among pregnant individuals with laboratory-confirmed ZIKV, the risk of congenital ZIKV infection ranged between 5% and 35%, and the risk of adverse pregnancy and birth outcomes ranged between 2% and 46%,17–25 66 with the high variability in adverse risk estimates due, in part, to the differing lengths of follow-up and outcome definitions use |
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