Transcript for VitalSigns Teleconference: Zika in Babies in US Territories

KATHY HARBEN: Thank you, Ted, and thank you all for joining us today for the release of a new CDC Vital Signs. This one is about babies with Zika-related health problems in the U.S. territories. We are joined by CDC Director Dr. Robert Redfield, Dr. Peggy Honein, who is the director of congenital and developmental disorders and we also have Dr. Lyle Petersen, he’s director of CDC’s division of vector-borne diseases. Dr. Redfield will provide opening remarks. Dr. Honein also has remarks and will answer questions and Dr. Petersen will also be available during the Q&A. I’ll turn the call over to Dr. Redfield.

DR. REDFIELD:  Thank you. Good afternoon and thank you for joining us today. CDC’s mission is to protect the health, safety and security of this nation. Each month in Vital Signs, we focus on a disease from the front lines of CDC science and what can be done about it to protect and save more lives. Today’s report contains new information about the health outcomes of babies born to mothers who had Zika during pregnancy and the medical care these babies need. Shortly after CDC’s response to Zika began, the U.S. Zika pregnancy and infant registry was established to monitor Zika’s impact on pregnant women and their babies. Today’s findings include the information on more than 4,800 pregnant women in U.S. territories who had laboratory evidence of Zika between 2016 and 2018. We are reporting on the health outcomes of 1,450 infants from these pregnancies who were at least one year old and had at least some follow-up care reported. What we found is that about one in seven, or 14% of these 1,450 babies, had one or more health problems possibly related to Zika. This includes some serious birth defects and nervous system problems that were not apparent at birth. Pregnancy and birth defect surveillance are key components of CDC’s preparedness work. Birth defects can be the first sign that an emerging infection can cause serious harm. CDC is a science-based data-driven service organization and critical data are provided by clinicians and territorial health departments. These partners have played a key role in providing the data to this registry which has helped us better understand the impact of Zika on pregnant women and their babies. By doing this surveillance in the United States and internationally, we can quickly detect emergency threats and strengthen our global health security. Remember. Diseases no-no borders and a health threat anywhere is a health threat everywhere.

Global health security is crucial to ensuring the health and safety of our nation. We are still learning about the effects of Zika and it might be years before we fully understand the full spectrum of the health outcomes related to Zika infection during pregnancy. We do know that babies may appear healthy at birth but can develop long-term health problems as they grow. That is why continued monitoring and follow-up evaluations are so crucial and health care providers play a key role in these efforts. By continuing to follow these babies and they age and grow we will learn more about Zika and remain alert to the problems that might develop over time. We than clinicians for their commitment to conduct all tests and evaluations to ensure appropriate care. So what do these findings mean for pregnant women and their families living in our nation today? Although this report is focused on babies born in U.S. territories, it is important to remember that almost 2,500 pregnancies in the United States also have laboratory evidence of Zika during the same time frame. Nearly all of these cases happened when pregnant women traveled to Zika-affected areas. CDC regularly issues guidelines to help people make decisions about travel and how to protect themselves against emerging health threats. Zika is still a risk, especially for pregnant women and their developing babies. CDC recommends pregnant women do not travel to areas with risk of Zika because infections during pregnancy can have consequences. for people who do travel to those areas or who live there, we know itis not easy but it is important to continue to take extra precautions about protecting against mosquito bites and getting Zika through sex.

Zika virus continues to spread at low levels and many areas of the world. Nearly a hundred countries and territories have a risk of Zika. The bottom line is Zika has not gone away and we must remain cautious both here in the United States and elsewhere. Now, I’m going to turn it over to Dr. Peggy Honein who will share the details about the important findings in this Vital Signs

DR PEGGY HONEIN: Thank you, Dr. Redfield. Today’s report focuses on information gained from our collaboration with the U.S. territories and freely associated states. These include American Samoa, Federated States of Micronesia, Puerto Rico, the Republic Marshall islands and the U.S. Virgin Islands. We plan to report about the health outcome on the babies born of mother with Zika during pregnancy in the continental U.S.A. and DC in the coming months. Today’s report is the largest to date involving longer term outcomes among babies born to mothers who had laboratory evidence of Zika during their pregnancy. These are the first published data on the health of babies in the U.S. at one year of age and older from the ongoing surveillance network of infants exposed to Zika before birth. As Dr. Redfield mentioned, over 4,800 pregnancies with lab evidence of Zika were identified in the U.S. territories and enrolled in the U.S. Zika Pregnancy and Infant Registry. From those pregnancies over 2,100 babies were one year or older by February of this year, the cutoff date for today’s report. What makes this report unique is that we’re looking at the health of these babies beyond what was observed at birth. We looked at medical information reported to the surveillance network as these children grew. We found that 1,450 infants or about two-thirds who were at least one year of age by the cutoff had some medical follow-up information after two weeks of age that was reported to our surveillance network. This report focuses on the health outcomes of and care received by these 1,450 babies. We do not yet have information on the health outcomes and care received by the remaining one-third of infants. We know that Zika infection during pregnancy can cause severe birth defects in infants and lead to lifelong health problems. We found that among these 1,450 babies who had some follow-up care reported, about one in seven, or 14%, had one or more health problems possibly related to Zika. Six percent had one or more Zika associated birth defects identified and reported which is over 30 times higher than the baseline for these brain and eye defects in the absence of Zika during pregnancy. About 9% of these children had at least one Zika associated nervous system neurological problem identified and reported to the surveillance network, such as seizures, problems with swallowing and moving, hearing loss or developmental delay based on standardized testing. We know that these health problems can lead to long-term functional challenges. Based on what we’ve learned about other congenital infections, we suspect health issues will continue to emerge as these children age. This is why it is so absolutely critical that these babies receive care to identify issues as soon as possible. This report identified opportunities for improvement in follow-up care. We were encouraged to see that 95% of babies in this analysis had at least one physical exam after the first two weeks of life about 76% of these babies had an evaluation to check their development and over half, or about 60%, received the recommended brain imaging after birth. However, based on the data we’ve received so far, only about half had the recommended hearing evaluation and only about one-third received an eye exam from a specialist. Parents and doctors need to work together to make sure all babies are evaluated, even babies that look healthy at birth. While this report describes data from the U.S. territories, it contains important reminders for health care providers serving families across the U.S. and globally. We urge health care providers and parents to remain vigilant. If a mother tests positive for Zika during pregnancy, it’s critical to share her test results with the babies’ doctors after birth so appropriate care can be provided. Pediatricians can ask every mother of a new baby about Zika exposure during pregnancy. If possible, Zika exposure during pregnancy is identified by these questions, extra monitoring is recommended for the baby. Some health problems can easily go undetected which is why it’s so important that these babies receive all the recommended care and evaluation even if they appear healthy. At each well-child visit, following clinical guidelines health care providers can ask parents questions about their child’s development. This activity is referred to as developmental monitoring and it can help health care providers identify any concerns with how that child is developing.

The American Academy of Pediatrics recommends that all babies receive an age-appropriate developmental screening using standardized validated tests at nine months of age, 18 months of age and 30 months of age. When problems are identified, referrals to specialty care such as neurology, ophthalmology, physical therapy or other specialties can be based on what is found by the clinical provider. Identifying health problems early can help babies and children get the services they need. For example, babies with eye problems might be fitted with special corrective lenses or receive eye exercises to help strengthen their eye muscles and babies with feeding problems might benefit from the services of a lactation specialist or gastroenterologist, who can work with the parents to make sure the baby is getting the nutrients that he or she needs. Babies with seizures might require medication to minimize their seizure events. Babies with developmental and learning delays might benefit from early intervention such as speech therapy, physical therapy and other types of services based on the needs of the child and the family. These services can improve the child’s ability to learn new skills, overcome challenges and will help us ensure every child gets the chance to reach their full potential.

Together clinicians and families can make sure every baby gets the care he or she needs. As Dr. Redfield mentioned earlier, everyone, especially pregnant women and their partners, should continue to take steps to protect themselves from Zika. In addition to reporting the health outcomes of affected babies, today we are also releasing updated guidance for couples thinking about becoming pregnant after Zika virus exposure or known Zika virus infection to prevent sexual transmission of Zika. This report includes a new CDC recommendation that men with possible Zika virus exposure or known Zika infection who are planning to conceive wait at least three months after they develop symptoms of Zika or after their last Zika exposure before trying to conceive. The previous guidance was that men wait at least six months before trying to conceive. These updated recommendations are based on emerging data suggesting the risk of infectious Zika virus in semen declined substantially during the three months after onset of symptoms all other Zika guidance remains unchanged. Please remember that CDC continues to recommend that pregnant women not travel to any areas with risk of Zika. Men with pregnant partners who have lived in or traveled to an area with risk of Zika can avoid transmitting Zika during sex by using condoms or abstaining from sex for the duration of the pregnancy. Because Zika associated birth defects and other health problems can occur in any trimester of pregnancy  People who travel to areas with risk of Zika can talk to their healthcare provider about the risks before they go and take extra precautions like using an EPA-registered insect repellent to avoid getting bitten by mosquitos. Pregnant women and their partners, who live in an area with risk of Zika, should take steps to prevent mosquito bites and prevent sexual transmission of Zika. Zika is now established and continues to circulate in places around the world, including in the U.S. Together we can take steps to prevent Zika infection during pregnancy and support families with babies that have been affected by Zika. The Zika story is not over, especially for the children and families who have been directly affected. Thank you and I’ll turn it back over to our moderator now.

KATHY HARBEN: Thank you, Dr. Honein. Ted, we are ready for questions and just a reminder that Dr.  Honein and Dr. Petersen are available.

OPERATOR. The first question in the queue is from Mike Stobbe with the associated press. Your line is open.

MIKE STOBBE Hi, thank you for taking my call. Two questions, Dr. Honein spoke to this a little bit but I was wondering what the background rate was. I think the doctor said for certain brain and eye defects what you found was that it was 30 times higher. I take it the background rate is 0.2%. But what’s the background rate for the other problems that were probably caused by Zika you were talking about seizures, movement difficulty. What’s the background rate for all of this compared to the 14% in this study?

DR. PEGGY HONEIN: In this report, 6% had Zika-associated birth defect which is you are correct is more than 30-fold higher than the background prevalence for the serious birth defects of the brain and eye which is about 0.16% among live-born infants in pregnancies that don’t have Zika infection. So more than a 30-fold increase for the Zika-associated birth defects. For the neurodevelopmental problems, we don’t have a similar baseline comparison. we looked at the neurodevelopmental problems that have been seen in children who have the most severe effects of Zika, for children with severe microcephaly and brain anomalies and they have seen the same types of neurodevelopmental disorders that we looked for in this report, problems moving and motor disabilities, seizures, swallowing problems, the joint contractures that make it difficult for them to move their arms and legs. In a population of children age one, we don’t have a good background prevalence and it really emphasizes how much more we have to learn about the full impact of Zika. We’re seeing these neurodevelopmental problems that are possibly linked to Zika in 9% of the children here including many children who didn’t have any Zika-associated birth defects and this is why parents and health care providers need to work closely together to follow up and monitor the development of children even if they look healthy at birth.

KATHY HARBEN: Next question, please.

OPERATOR: Next question is from Susan Scutti with CNN. Your line is now open.

SUSAN SCUTTI: When was the last documented introduction of Zika into the mainland U.S.?

DR. PEGGY HONEIN: There hasn’t been any local transmission of Zika in the continental U.S. in 2018 and I will turn to Dr. Petersen on the phone to see if he has the specifics on the last local transmission in the continental U.S.

DR. LYLE PETERSEN: Do not have the exact date but it was in late 2016.

KATHY HARBEN:  Next question, please?

OPERATOR: Next question is from Andrew Joseph with STAT, your line is open.

ANDREW JOSEPH: Thanks. Were you able to figure out if there is an association between these neurodevelopmental abnormalities in the timing or I guess trimester of infection in pregnancy?

DR. PEGGY HONEIN: We have not yet assessed the timing of pregnancy and the role that has on neurodevelopmental abnormalities, but we do know for Zika-associated birth defects that the highest risk is in the first part of pregnancy. But there is a risk of Zika-associated birth defects with infection in any trimester of pregnancy which is why it’s important pregnant women not go to areas of risk throughout their pregnancy and if they’re living in an area of risk of Zika they take precautions to prevent transmission throughout the entire pregnancy.

OPERATOR: Next question is from Melissa Healey with the “Los Angeles times.” your line is open.

MELISSA HEALEY: Hi, thanks for taking my call. I want to clarify a little bit about the population of babies that made up the study population here. Were all of these women were infected in the United States? Were they all U.S. residents? Or did they simply all have their babies in the united states? I’m trying to distinguish what makes these women different, say, from Brazilian women who were infected in Brazil.

DR. PEGGY HONEIN: so the 4,800 pregnancies that we’re reporting on from the U.S. territories and freely associated states were women who delivered their pregnancies in one of those U.S. territories or freely associated states. So in all likelihood they were also infected because all of those places had local transmission of Zika, but all of them completed their pregnancy in the U.S. territories and freely associated states. The follow-up care could be received from anywhere where those children received follow-up care so we know, for example, Puerto Rico and the U.S. Virgin Islands were heavily hit by the hurricanes in 2017. Some families were displaced to the continental U.S. and where it was possible to identify where people had been displaced to, follow-up information up to a year old could come from their new location or their original location.

OPERATOR: Next question is from Lauren Clayson with CQ. Your line is now open.

LAUREN CLAYSON: I was wondering, if you guys expect the incidents to increase as these children get older? If you expect — all these children you said are at least one year old but as they get to two years or three years, do you expect more symptoms or there a cutoff for when these symptoms will appear??

DR. PEGGY HONEIN:  Based on what we know about other congenital infections we expect to learn more as these children grow and develop and additional problems are identified and diagnosed. It’s also important to emphasize that all 1,450 of these babies were at least a year old but we didn’t necessarily have complete follow-up information to a-year-old old and we know not all of them had data on specific evaluations like eye exams reported to the surveillance network. So as we learn more, we are likely to identify additional children with health problems, such as vision problems, hearing problems, motor disabilities, cognitive disabilities. So the Zika story is not really over, and we have so much more to learn.

OPERATOR: Next question is from Donna Young with S&P Global News. Your line is now open.

DONNA YOUNG: Thank you for taking my question. First of all, could you clarify when you talk about in the report the 2,500 pregnancies in the U.S. are you talking about those specifically in states like Miami as well? Because that’s a little confusing when you’re talking about the — within the report, are those continental U.S. states versus U.S. territories? And, also, are you able to talk a little bit at all about the status of the Zika virus vaccine development? Thank you.

DR. PEGGY HONEIN: Thank you. So CDC’s surveillance network for monitoring the pregnancies and infant outcomes resulting from Zika infection during pregnancy includes infants from 7,300 pregnancies in the U.S. states and territories combined. about 2,500 of those are in the U.S. states and D.C. and those are not included in today’s report and about 4,800 of those pregnancies are in the U.S. territories and freely associated states which is the topic of today’s report and these were the areas hardest hit by Zika with local transmission of Zika throughout them. From these 4,800 pregnancies, about half of them had babies that were at least a year old and about 2/3 of those one-year-olds, we had some follow-up information reported to us. So, that’s where the 1,450 babies in the report comes from. I’m sorry, you had a second question? On the vaccine? Lyle, did you want to provide a brief update on the vaccine?

DR. LYLE PETERSEN: First, I’d like to make a correction; the last cases of locally-transmitted Zika virus infection were in 2017. We had two in Florida and five in Texas but as Dr. Honein indicated; there’s been no local transmission so far in 2018. As far as the Zika virus vaccine, I think questions regarding the vaccine and the current status are best directed to the National Institutes of Health who are organizing that effort.

KATHY HARBEN: We have time for a couple more questions. Next question, please.

OPERATOR: Next question is from Kerry Sheridan with AFP, your line is now open.

KERRY SHERIDAN Thanks for taking my question. I have two. Could you discuss about the race of birth effects in this population and if or how it varies from the children affected by the Zika in Brazil? My second question is why do you think — you mentioned you don’t have information on the remaining one-third of babies yet. Why is that? Thanks.

DR. PEGGY HONEIN: Thank you for that question. So in estimating the impact that Zika during pregnancy has on babies, one important feature is the criteria you use to define the adverse outcomes for the health problems of interest. So CDC has established a criteria which includes microcephaly, defects of the brain, and eye problems as meeting the criteria for Zika-associated birth defects. Using those criteria in a variety of countries, we’ve pretty consistently seen 5% to 10% of the babies from pregnancies with Zika having one of these brain or eye defects or microcephaly. There have been some reports that have used different criteria and included a broader range of outcomes, including some findings on MRI imaging of unknown clinical significance. And if you use broader criteria, you will see more babies affected, but based on the CDC criteria, we’ve seen on reports in numerous countries and we think there is a geographic difference, but more a case criteria difference and prevalence of Zika-associated birth defects. For the one-third of babies that we don’t have follow-up information yet. It really speaks to the complexity of following up pediatric care for people that may see a variety of providers or may move and seek care in other settings. So we’re continuing to work very closely with the territorial health departments as well as state health departments to follow up on all of the children who have been impacted by Zika during pregnancy. We really urge parents and health care providers to work closely together to make sure all children are receiving the care and evaluation they need and as more children receive that care and that information as reported to state and territorial health departments, it will improve our ability to understand the full impact of Zika on these children.

KATHY HARBEN: We have time for one final question.

OPERATOR: The final question is from the associated press. Your line is open.

MIKE STOBBE:  Hi, thanks for letting me go again. I had another part of my earlierquestion. First of all, I wanted to ask Dr. Petersen. you said the last local transmission was in 2017 and you were talking about Florida and Texas. When was the last local transmission in Puerto Rico and one of the territories? Also could you speak to — I think the language was that these 14% possibly were related to Zika, could you say a little more about what does possibly mean? It’s very likely or know there are other possible explanations why some of these children have these? And the last question was could you say a little more about possible reasons why in Puerto Rico or other territories that the children didn’t get all the evaluations that would have been recommended? Thank you.

DR. PEGGY HONEIN: Lyle, would you like to start?

DR. LYLE PETERSEN: Sure. so far in 2018 there’s been 74 cases of Zika virus reported in the U.S. territories, almost all in Puerto Rico. There’s one caveat to this 74 cases, however. Most of these cases were in symptomatic people who were diagnosed with the antibody test or the IGM antibody test. What we do know is that the IGM antibody test remains positive in some people for longer than a year, so it’s often very difficult to determine whether some of these symptoms are really due to Zika virus or not. If they do have a positive anti-body test although they are classified as cases but we know there is still ongoing transmission in Puerto Rico. It’s at a much lower level than obviously we’ve seen in previous years but there is ongoing transmission currently.

DR. PEGGY HONEIN: And to follow up on your questions on causal versus possibly? There’s sufficient evidence that accumulated early on the emergency response to know that Zika can cause serious birth defects including microcephaly, the brain abnormalities and the eye defects we have seen in many of these children. With the neurodevelopmental problems we calling them possibly caused by Zika because we are still learning much more about how often these happen, how often these would happen in one-year-old children without Zika. We’re very focused in on the same neural developmental problems that we see with children who have some of the severe birth defects and those small case groups of severely affected children that have been followed up and this is really providing us with the first clues about how common some of these neurodevelopmental disabilities might be, and an entire cohort of children that are impacted by Zika during pregnancy. So we’re learning more. We know that all of these children regardless of the cause of the neurodevelopmental disorder need referrals to receive the interventions and have the best outcomes possible. But we can’t say with certainty how many of these neurodevelopmental problems were caused by Zika. I think, it emphasizes that the Zika story is not yet over. We’re still learning more everyday about the full impact of these infections. There was a report released last Thursday with some CDC co-authors with older children with severe congenital Zika syndrome whose mothers were infected in Cambodia in 2009 and 2011, and those children provide us some of the clues about the complex medical care that is needed for these severely affected children if they grow and develop, so much more to learn.

KATHY HARBEN: Thank you very much Dr. Redfield, Dr. Honein and Dr. Petersen. Thank you to the reporters who joined us today. If you have follow-up questions, you can call the press office, here at CDC at 404-639-3286 or you can e-mail us at media @CDC.gov. Thank you for joining us. This conclude our call.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES