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Public health

Q&A: The story on the Zika virus and microcephaly so

far
The Pharmaceutical Journal10 FEB 2016 By John Zarocostas

David Heymann talks about the Zika virus and microcephaly, the
latest global public health emergency, and what is being done to
tackle it.

Source: epa european pressphoto agency b.v. / Alamy Stock Photo

David Heymann is chair of the International Health Regulations emergency committee. He is also
professor of infectious disease epidemiology at London School of Hygiene and Tropical
Medicine, the head of the Centre on Global Health Security at Chatham House, London, and
chairman of Public Health England. Previously he was the World Health Organization (WHO)
assistant director general for health security and environment, and representative of the director
general for polio eradication.
From 1998 to 2003, he was executive director of the WHO communicable diseases cluster,
during which he headed the successful global response to severe acute respiratory syndrome and,
before that, was director for the WHO programme on emerging and other communicable
diseases.

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Before joining the WHO, he worked for 13 years as a medical epidemiologist in sub-Saharan
Africa, on assignment from the US Centers for Disease Control and Prevention (CDC), where he
participated in the first and second outbreaks of Ebola haemorrhagic fever, and supported
ministries of health in research aimed at better control of malaria, measles, tuberculosis and other
infectious diseases.
On 1 February 2016 WHO director general Margaret Chan declared that the recent cluster of
microcephaly cases and other neurological disorders reported in Brazil, following a similar
cluster in French Polynesia in 2014, constitutes a public health emergency of international
concern.

What are your aims now that a public health emergency has been called
for microcephaly?
Because the public health emergency was called for the microcephaly instead of the Zika virus,
we can do better surveillance and understand which countries that have a Zika outbreak also
have microcephaly and other disorders. This requires a standardised case definition and
collaborative efforts to determine whether or not there is a link between the microcephaly and the
virus.

Is this more a precautionary health emergency compared with earlier

ones we have seen such as Ebola or H1N1?
I would like to say it is an emergency because there is so much that we do not understand right
now. First of all, it is not even clear whether or not there are clusters of microcephaly or whether
theyre using a right gauged definition throughout the world. And those are the things that are
being examined right now by the WHO.
Zika is a virus like dengue or chikungunya, and they require vector control

The precautionary measures are for Zika because its a virus like dengue or chikungunya, and
they require vector control [any method to limit or eradicate the mammals, birds, insects or other
arthropods vectors which transmit disease pathogens]. We need to understand how
infection occurs in order to prevent it from happening, and we need to consider whether a vaccine
could be developed. So the precautionary measures are on the virus, whereas the urgency and
emergency measures are on the microcephaly.

Is the increase in Guillain-Barre syndrome cases, which can cause

paralysis and death, also of concern?
Guillain-Barre is a rare but serious event, and it can happen when theres a reaction to antibiotics,
a vaccine or a viral infection. So, if theres an increase of these cases, then theres a different
reaction to Zika compared with other viruses. But this has to be verified by standardised
surveillance and thats the appeal for standardised surveillance and research to determine
whether or not theres a link.

The WHO has said that up to 4 million people could be infected with Zika
in the Americas, of which 1.5 million alone will be in Brazil. What about
the rest of the world? Are they also at risk?
The virus is already known to circulate in Africa and in Asia. It is known to have been in India
also. Now it has made it to Latin America. So really it has just been travelling around the world.

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Will disease surveillance be essential here?

Yes, we need to be looking to see if there are clusters of microcephaly that are occurring where
Zika outbreaks occur. But you have to wait nine months after the outbreak to determine the link.

How far off are we from an effective vaccine, given there is no effective
vaccine against Dengue, which the same vector the yellow fever
mosquito spread?
Its not clear how far off we are from a vaccine. But there first has to be basic research to develop
the strains that go into a vaccine. Then it has to be tested in the animal model and, if it has been
shown to be safe and effective in an animal, then it goes into safety and effectiveness studies in
humans. So, were probably talking about years after the initial development is done.

Do we know which bodily fluids the virus is present in?

There have been reported cases of sexual transmission and also through blood transfusion. There
will be further examinations in all these cases. Hopefully, the WHO will be able to coordinate,
which should give an idea of where the risks are.

Do we know how the virus causes the characteristic symptoms of the

disease?
In more than 80% of cases, the disease is very mild and causes few symptoms (e.g. fever, rash).
But again, theres not a lot of experience with it because it is so benign to human health.

Do we know by what mechanisms the Zika virus could cause congenital

malformations and neurological abnormalities?
No, and it is important to stress that we dont even know if it does it yet. Therefore, we could not
possibly postulate how. First of all, there has to be a causal link between the two, which
incidentally, there has been in a virus identified in a few specimens from children with
microcephaly. But thats not confirmation, just coincidental. We call this circumstantial evidence,
but its not proof.
We dont even know if the Zika virus definitely causes congenital malformations

Do you think you will need to rally resources like we saw in the Ebola
outbreak?
In this case, different types of resources have to be mobilised compared with Ebola. We need
money to take care of vector control, and we need money for research to determine whether or
not theres a linkage between the virus and microcephaly.

Is there any research to see if this virus is mutating?

There are genetic studies happening. I would be looking for a change in the structure of the
genome to see if there were changes. Those changes might be the cause of the change in
virulence and if indeed there is a link between Zika and microcephaly.
Citation: The Pharmaceutical Journal, PJ February 2016 online, online | DOI:
10.1211/PJ.2016.20200668

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