Soon after January’s Zika virus travel alert, Christine Curry, MD, PhD, found herself at the leading edge of a public health emergency. Florida Governor Rick Scott declared the emergency in several counties, including Miami-Dade, where Curry is an assistant professor of obstetrics and gynecology at the University of Miami Miller School of Medicine. The university’s health system moved quickly to provide services for pregnant patients, while referrals came in from community physicians uncertain about the virus and its link with microcephaly during fetal development.
Christine Curry, MD, PhD
In the midst of it all, Curry’s colleagues chose her as the designated point person for obstetrics-related Zika virus issues. She keeps pregnant patients well informed and in late March was caring for 2 of Florida’s 4 pregnant women known to have Zika virus infection. Curry helps update faculty and staff with information channeled through university-wide emails that summarize guidelines, protocols, and other news. “If people are in a hurry, they can just read it on their phone,” she said.
She’s also involved in updating the medical school website with links to the Centers for Disease Control and Prevention (CDC). “If someone in Miami is scared and they’re typing in pregnancy, Miami, and Zika, that’s going to pull up the website and give them facts so their fears can be managed in an evidence-based way,” she added.
In fact, Curry has added the CDC website to her own morning routine. “It’s the first thing that I look at when I wake up,” she notes. Recently, Curry spoke with JAMA about the challenges of caring for pregnant patients while keeping up with a fast-moving outbreak. The following is an edited version of the interview.
JAMA:When the CDC travel alert came out, what first steps did you and your colleagues take to care for patients and keep them informed?
Dr Curry:We assembled a team of infectious disease specialists, obstetricians, and pediatricians to have a coordinated plan so that when one of these patients presented we were following a protocol and making sure we were giving them up-to-date information.
JAMA:What are some of the most problematic uncertainties you’ve dealt with?
Dr Curry:We don’t know the exact consequences to the fetus if a pregnant woman is infected. When a patient says she traveled to a Zika-infected area, I don’t know what fraction of the mosquito bites put her at risk. Even if she’s bitten, we don’t know how many patients who are symptomatic or asymptomatic are going to transmit that infection to the pregnancy. And even if a pregnant woman is infected, we can’t counsel her on what percent of those pregnancies have neurologic or developmental problems going forward. We don’t have hard numbers to give patients so they can weigh the risks and benefits.
JAMA:How has your day-to-day work changed since the travel alert came out?
Dr Curry:There is now a cohort of patients that we’re following and trying to provide with good clinical care and good counseling. That cohort of women is just going to grow larger. So it’s a matter of creating systems to manage more frequent ultrasounds and making sure that test results don’t fall through the cracks so that the patients don’t feel scared and nervous because they’re not sure what’s going on.
JAMA:A recent Medscape poll showed that 70% of ob/gyns [obstetricians/gynecologists] are aware that Zika could show up in the United States, but only about 39% feel even somewhat prepared to care for patients with the infection. Does that surprise you?
Dr Curry:That is not a scientific poll, but I would say that it’s not surprising that, when something is brand new and incredibly fast-moving, the average health care provider doesn’t spend a lot of time every day keeping up on the latest articles on Zika.
JAMA:Guidelines are available from the CDC, the American Congress of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine. How helpful are they, given the unknowns?
Dr Curry:The guidelines are very crisp and clear. The CDC, ACOG, and SMFM essentially have the same message in terms of who to test for blood, who to do ultrasounds on, and who to do amniocentesis on. It’s straightforward, but we don’t know enough yet to say, “Because this test is positive, these are the consequences to your fetus.”
JAMA:When you get a positive immunoglobulin M test, don’t the possibilities of cross-reactivity with other flaviviruses, like dengue or yellow fever, increase the difficulties in interpreting what a positive test really means?
Dr Curry:The positive test still has some uncertainty to it. There are ways to make that test a bit more precise, but it’s not a perfect test. And so during counseling, you have to include the phrase, “I’m not sure,” or “I don’t know,” and not give the illusion that we as health providers and we as obstetricians know the exact outcome or answer for someone’s pregnancy.
JAMA:How far into a pregnancy can you determine whether the fetus would have microcephaly, and how do you counsel the mother if that appears to be the case?
Dr Curry:The second trimester may be the earliest that we can detect differences noticeable enough to tell the mom we’re concerned for microcephaly, although it may be something that we don’t detect until the third trimester. The timing is really important, particularly in countries where abortion is legal, because some women would choose, rather than to live with the uncertainty, to end the pregnancy because the potential for a really profound effect on the fetus exists. And so the timing of testing and of recognition for exposure is really important.
JAMA:And those timing issues are in the guidelines from the professional associations?
Dr Curry:Yes. The moment that a health care provider recognizes a woman is pregnant and has traveled to an area of ongoing Zika virus transmission, that is the time to initiate testing. When I send a specimen out of my clinic, the time until I get the report back has been up to 3 weeks. Each step of the way, there’s a lag between the patient traveling, the patient presenting for care, the blood test being sent, and getting the blood test result. In every step, there’s delay in a very time-sensitive set of decisions.
JAMA:Three weeks can be a long time for the mother to wait. What kinds of services are available to her during that time?
Dr Curry:At the University of Miami, patients who qualify for testing are seen in one of our centralized clinics where specimens are drawn, their history is taken, and they get links to the most up-to-date information. We don’t have much printed information because it’s outdated so quickly, so we refer them to the CDC largely to make sure that they can read to their heart’s desire. Then I see the patients if they want more information. I’m doing my best to stay up-to-date so they feel like they can have conversations about the newest information. And then whatever they choose to do concerning their pregnancy, we support them throughout that.
JAMA:Counseling on the risk for sexual transmission also is involved. Are patients surprised by that?
Dr Curry:I think everyone is surprised by that. We don’t know what the risk [of sexual transmission] is, and we don’t know what the consequences are. When I ask patients, “Have you traveled?” and they say no, I think they breathe sigh a relief that they’re not at risk. Then when we start talking about their sexual partners, they are really surprised that might be something that could put them and their pregnancy at risk. So it ends up being an unexpected conversation for most patients.
JAMA:Is the counseling the same as for any sexually transmitted disease?
Dr Curry:Thankfully, it is the same—correct and consistent condom use with each act of intercourse, specifically until the end of pregnancy.
JAMA:Some physicians may feel fairly removed from the Zika virus outbreak because they’re located far from the affected countries. What would you say to them?
Dr Curry:Whether you are in New York City, California, Texas, or Miami, if your patients travel to 1 of these countries, they all have similar risks. Consider instituting a universal question at each OB visit to briefly ask if your patient has traveled in the last year. If not, give her the travel recommendations from the CDC. This is a quick, 60-second way to check with each patient. We see OB patients so frequently that it’s easy to modify and change our guidance as more information arises.
JAMA:If you could get the answer to just 1 of the unknowns, what would it be?
Dr Curry:The most clinically relevant question is, in a woman infected with Zika virus, what are the predictable effects to the pregnancy? If you can answer that, the rest of the counseling falls into place. But without the ability to directly tell a patient her test is positive and the consequences are X, Y, and Z, it’s hard for the patient to feel autonomy and to feel comfortable making decisions.
Voelker R. Miami Obstetrician Uses Evidence to Quell Zika Fears. JAMA. 2016;315(19):2051-2052. doi:10.1001/jama.2016.4069