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Brain Damage in Zika Babies Is Far Worse Than Doctors ExpectedResearchers say the Zika virus attacks lobes of the fetal brain that control thought, vision, movement Janeusa Primo Chagas, head of neuropediatrics at a hospital in Salvador, Brazil, examines brain images. Hundreds of mothers in Brazil have given birth to babies with microcephaly that have disabilities more severe than in textbook cases. PHOTO:LUCIANA MAGALHAESBy LUCIANA MAGALHAES and BETSY MCKAYUpdated April 28, 2016 1:00 p.m. ET106 COMMENTSSALVADOR, Brazil—Ana Gabriela do Prado Paschoal sat at a desk in a small medical exam room and began a familiar, heartbreaking ritual. Your baby’s head is smaller than normal, Dr. Paschoal told the anxious mother, who had contracted the Zika virus while pregnant. The 3-month-old girl, Maria Luiza, also had lesions on her brain. Her muscles were stiffer than normal, a sign of brain damage. Maria Luiza would take longer to walk and talk, Dr. Paschoal told the mother, a 24-year-old farmworker. More serious complications were likely, but the doctor decided that was enough news for one day. The scale and severity of prenatal damage by the Zika virus are far worse than past birth defects associated with microcephaly, a condition characterized by a small head and brain abnormalities. Scans, imaging and autopsies show that Zika eats away at the fetal brain. It shrinks or destroys lobes that control thought, vision and other basic functions. It prevents parts of the brain not yet formed from developing. Related Video As many as 1.5 million Brazilians may be infected by the mosquito-borne Zika virus. With Brazil at the forefront of the latest global health scare, and as the host of this year’s Olympic Games, Dipti Kapadia explains three things Brazil is doing to combat the Zika virus. Photo: Getty Images Drugmakers are fast-tracking efforts to develop a vaccine to treat the Zika virus, which has been linked to serious birth defects. WSJ’s Peter Loftus reports. Photo: Scripps Research Institute“These aren’t just microcephaly, like a slightly small head. The brain structure is very abnormal,” said Jeanne Sheffield, director of maternal-fetal medicine at the Johns Hopkins School of Medicine, who has been counseling pregnant women about microcephaly for two decades. Microcephaly, a rare birth defect that affects about 6 out of 10,000 babies in the U.S., is often associated with developmental delays and intellectual disabilities. But some children are only mildly affected. The Zika-related cases in Brazil nearly all involve significant brain damage. The sickest Zika babies in Brazil have died before delivery or within hours of birth. No one knows yet how long the survivors will live or how much they can be helped in the years ahead. Brazil is now bracing for a second stage of the 6-month-old crisis: Caring for infants with a wide range of disabilities. Experts have begun calling the constellation of maladies linked to the virus Congenital Zika Syndrome—to describe the babies born with disabilities more severe than in textbook microcephaly cases. Often, liquid fills the spaces where there is no brain tissue. Brazilian Silvia Leandra de Jesus Pinheiro says her life has been turned upside down since her daughter Geovanna was born in October with microcephaly. The baby’s physicians have told her that Geovanna could have trouble with speech and movement. ‘My hope is that she gets there, even if it’s after other kids her age,’ she said. PHOTO: LUCIANA MAGALHAES“There are areas of the brain that aren’t even formed,” said Janeusa Primo Chagas, head of neuropediatrics at the hospital operated by Sister Dulce, a philanthropic organization, where Dr. Paschoal also works. Baby Maria Luiza was one of more than 1,000 newborns since October with birth defects that are suspected of links to themosquito-borne Zika virus. Many of the 130 infants in the care of Drs. Chagas and Paschoal may never learn to talk or walk, Dr. Chagas said. Some will have trouble seeing. Many could develop epilepsy. “It’s safe to say almost all of them will require long-term, continual care,” said Edwin Trevathan, professor of neuroscience at Baylor University and a former director of the U.S. Centers for Disease Control and Prevention’s national center on birth defects and developmental disabilities. Breaking the news to new mothers makes the work difficult for doctors. Mothers sometimes arrive for appointments excited because their babies’ heads have grown. Dr. Chagas has the job of telling them the change isn’t a sign of improvement, but a buildup of fluid in the head that must be drained. Dr. Paschoal, a neuropediatric resident, often tries to soften the news, as she did with Maria Luiza’s mother, Eliane Moreira de Carvalho, because it is impossible to know the severity of the birth defects now unfolding. Ms. Carvalho was upbeat after the consultation. “Now, we have to move forward and take care of her,” she said. The young mother said she won’t have more children so she can concentrate her attention on Maria Luiza. Her husband also works in agriculture, and the family gets financial aid from the government to help make ends meet. Maria Luiza has several brain abnormalities: The corpus callosum, which connects the two hemispheres of the brain and communicates between them, didn’t form properly. Her right eye could be impaired, another sign of brain damage. “We’re careful when we talk to them because no one wants to receive this kind of news,” Dr. Paschoal said. After seeing the first few cases last fall, Dr. Paschoal said, she wanted to cry. The 29-year-old medical resident is afraid to have her own children, she said: “I want to have them, but you don’t think about a thing like this.” New risksScientists are trying to understand how a virus that has appeared benign since first identified nearly 70 years ago could now pose such a grave risk. One possibility, they say, is that serious complications went mostly unnoticed as the virus spread from Africa to Asia and the Pacific islands. Infections might have passed largely through poor countries without effective disease tracking, or the outbreaks could have been much smaller, making complications harder to spot. Scientists are also exploring whether mutations developed in the virus that made it more virulent or easily transmissible as it moved around the world. Researchers have looked back at medical records from pregnancies and births during and after a Zika outbreak in French Polynesia that occurred in 2013 and early 2014. They discovered 19 fetuses and newborns with brain abnormalities similar to those now seen in Brazil; six of the babies are alive but severely impaired, said a study published in March. Experts in child development say the Zika virus may trigger other birth defects that won’t be detected until after these babies grow. Ana Gabriela do Prado Paschoal, a neuropediatric resident in Salvador, Brazil. The 29-year-old doctor is afraid to have her own children, she said: ‘I want to have them, but you don’t think about a thing like this.’ PHOTO:LUCIANA MAGALHAES“We do anticipate there would be a spectrum of outcomes,” said Margaret Honein, an epidemiologist on a pregnancy-and-birth-defects task force belonging to the CDC’s Zika response. There could be hidden problems with the brain that don’t show up as microcephaly, for example. Without a vaccine for Zika, public-health authorities are trying to control mosquitoes spreading the virus. They are providing mosquito repellent and, in some places, contraceptives, to women of childbearing age. Outbreaks have been reported for the first time in 42 countries and territories since last year, most in Latin America, according to the World Health Organization. Health officials and experts in Brazil say the epidemic is peaking, with the number of Zika cases expected to fall in coming months. That forecast is based on dengue fever—transmitted by the same Aedes aegypti mosquito—which usually subsides in May as the weather cools for winter in the Southern hemisphere. North of the equator, U.S. officials are preparing for the possible spread of Zika this summer, particularly in the Gulf states. At least 33 pregnant women in the U.S. have been infected. Some have miscarried or their fetuses developed abnormalities. Health officials say large outbreaks in the U.S. are unlikely because of wide use of air conditioning and window screens, as well as disease tracking. The CDC has tallied 388 Zika cases in the U.S. and 503 in U.S. territories, predominantly Puerto Rico. Public health officials worry Brazil could mark the beginning of a wave of infants born with birth defects in Latin America and the Caribbean. Colombia has started reporting cases. The virus has already spread quickly from Paraguay to Mexico. Of particular concern are poor countries that lack advanced health-care services for pregnant women, as well as repellents, window screens and other mosquito protections. Brazil’s government pledged to spend 796 million reais this year, about $225 million, to diagnose and treat babies with microcephaly. Public-health organizations say they will need more. In a small therapy room at the Pedro I municipal hospital in Campina Grande, at the center of the Zika epidemic, a physical therapist placed Nicolas Felipe de Oliveira face up on a large green mat and stretched his stiff legs. Nicolas could lift and move his head a bit. When the therapist stretched him across a big yellow exercise ball, he burst into tears. Nicolas, currently five months old, now lifts his head and smiles, said his grandmother, Ivaneide Matias. He still cries often, she said. Physicians hope early stimulation will minimize the disabilities, said Rogerio Gomes, the coordinator at Instituto Bahiano de Reabilitação in Salvador. In March, the facility started offering therapy to stimulate the Zika babies, using techniques established for other disabilities. Therapists sing songs to the babies and use contrasting patterns to grab their attention. Some of the infants have difficulty making eye contact, the therapists said. The weekly sessions last about 80 minutes, usually attended by three mothers and their babies. They work with a team that includes a psychologist, physical therapist, occupational therapist and speech therapist. “Every week you observe gains,” said therapist Elane Bahia Lemos.“It doesn’t mean that from one week to another, they will be able to hold their heads, it’s a process.” Keeping hopeSilvia Leandra de Jesus Pinheiro says her life has been turned upside down since her daughter Geovanna was born in October with microcephaly. “I was still at the delivery table,” Ms. Pinheiro said, when she learned, though she suspected something was wrong. She had a fever in her seventh month of pregnancy last year. Geneticist Diego Miguel, who saw Geovanna at the end of March, said he was treating her case as Zika-related because she was born during the outbreak and her birth defects fit the pattern. Geovanna’s head measured 29.5 centimeters when she was born, 2 centimeters below normal. The ventricles in her brain are dilated and she has lesions on her frontal lobe, according to scans conducted at birth. Her legs are stiff and she keeps her fists clenched. Clicia Nunes, of the Instituto Bahiano de Reabilitação in Salvador, Brazil, examines Geovanna de Jesus Pinheiro during a recent visit. The baby was born with defects believed to be related to Zika. PHOTO: LUCIANA MAGALHAESMs. Pinheiro, a 33-year-old elementary-school teacher, said she was able to quit her job to take care of her daughter full-time because her husband owns a small business as a cellphone technician. She takes Geovanna to physiotherapy for twice-weekly sessions. The baby’s physicians have told her that Geovanna could have trouble with speech and movement. “I know there will be delays,” she said, “but my hope is that she gets there, even if it’s after other kids her age.” Clicia Nunes Santos Ferreira, a physician who specializes in physical therapy and rehabilitation at the Instituto Bahiano, said she had treated 10 cases of microcephaly over about nine years before the Zika epidemic. “There are some who may develop, but others not,” she said. “This is all very new. We do not know what will become of this generation.” Write to Luciana Magalhaes at [email protected] Betsy McKay at [email protected] http://www.wsj.com/articles/brain-damage-in-zika-babies-is-far-worse-than-doctors-expected-1461859591

Zika Virus – April 28, 2016. Texas has had 31 confirmed cases of Zika virus disease. Of those, 30were in travelers who were infected abroad and diagnosed after they returned home; one of those travelers was a pregnant woman. One case involved a Dallas County resident who had sexual contact with someone who acquired the Zika infection while traveling abroad. Case counts by county: Bexar – 3Dallas – 6Denton – 1Fort Bend – 2Grayson – 1Harris – 12Tarrant – 3Travis – 2Wise – 1

April 28, 2016 DEPARTMENT OF HEALTH DAILY ZIKA UPDATE: NO NEW CASES TODAY Contact:Communications [email protected](850) 245-4111 Tallahassee, Fla.—In an effort to keep Florida residents and visitors safe and aware about the status of the Zika virus, the Florida Department of Health will issue a Zika virus update each week day at 2 p.m. Updates will include a CDC-confirmed Zika case count by county and information to better keep Floridians prepared. There are no new cases today. Of the cases confirmed in Florida, two cases are still exhibiting symptoms. According to the CDC, symptoms associated with the Zika virus last between seven to 10 days. Based on CDC guidance, several pregnant women who have traveled to countries with local-transmission of Zika have received antibody testing, and of those, five have tested positive for the Zika virus. The CDC recommends that a pregnant woman with a history of Zika virus and her provider should consider additional ultrasounds. It is recommended that women who are pregnant or thinking of becoming pregnant postpone travel to Zika affected areas. County Number of Cases (all travel related) Alachua 4 Brevard 2 Broward 15 Clay 1 Collier 1 Hillsborough 3 Lee 4 Miami-Dade 39 Orange 5 Osceola 4 Palm Beach 5 Polk 3 Santa Rosa 1 Seminole 1 St. Johns 1 Cases involving pregnant women* 5 Total 94 *Counties of pregnant women will not be shared. On Feb. 12, Governor Scott directed the State Surgeon General to activate a Zika Virus Information Hotline for current Florida residents and visitors, as well as anyone planning on traveling to Florida in the near future. The hotline, managed by the Department of Health, has assisted 1,550 callers since it launched. The number for the Zika Virus Information Hotline is 1-855-622-6735. All cases are travel-associated. There have been no locally-acquired cases of Zika in Florida. For more information on the Zika virus, click here. The department urges Floridians to drain standing water weekly, no matter how seemingly small. A couple drops of water in a bottle cap can be a breeding location for mosquitoes. Residents and visitors also need to use repellents when enjoying the Florida outdoors. More Information on DOH action on Zika: On Feb. 3, Governor Scott directed the State Surgeon General to issue a Declaration of Public Health Emergency for the counties of residents with travel-associated cases of Zika.There have been 15 counties included in the declaration– Alachua, Brevard, Broward, Clay, Collier, Hillsborough, Lee, Miami-Dade, Orange, Osceola, Palm Beach, Polk, Santa Rosa, Seminole and St. Johns – and will be updated as needed. DOH encourages Florida residents and visitors to protect themselves from all mosquito-borne illnesses by draining standing water; covering their skin with repellent and clothing; and covering windows with screens.DOH has a robust mosquito-borne illness surveillance system and is working with the CDC, the Florida Department of Agriculture and Consumer Services and local county mosquito control boards to ensure that the proper precautions are being taken to protect Florida residents and visitors.On April 6, Governor Rick Scott and Interim State Surgeon General Dr. Celeste Philip hosted a conference call with Florida Mosquito Control Districts to discuss ongoing preparations to fight the possible spread of the Zika virus in Florida. There were 74 attendees on the call.Florida currently has the capacity to test 6,576 people for active Zika virus and 1,405 for Zika antibodies.Federal Guidance on Zika: According to the CDC, Zika illness is generally mild with a rash, fever and joint pain. CDC researchers have concluded that Zika virus is a cause of microcephaly and other birth defects.The FDA released guidance regarding donor screening, deferral and product management to reduce the risk of transfusion-transmission of Zika virus. Additional information is available on the FDA website here.The CDC has put out guidance related to the sexual transmission of the Zika virus. This includes the CDC recommendation that if you have traveled to a country with local transmission of Zika you should abstain from unprotected sex.For more information on Zika virus, click here. About the Florida Department of Health The department, nationally accredited by the Public Health Accreditation Board, works to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts. Follow us on Twitter at @HealthyFla and on Facebook. For more information about the Florida Department of Health, please visit www.FloridaHealth.gov. http://www.floridahealth.gov/newsroom/2016/04/042816-zika-update.html

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As of Thursday, April 28, 2016, VDH has reported 13 cases of Zika virus disease in Virginia residents to the CDC (2 in Northwest Region, 5 in Northern Region, 1 in Eastern Region, 3 in Central Region and 2 in Southwest Region). CDC has issued a travel alert (Level 2-Practice Enhanced Precautions) for people traveling to regions and certain countries where Zika virus transmission is ongoing. http://www.vdh.virginia.gov/epidemiology/zika-virus-update/

As of Thursday, April 28, 2016, VDH has reported 13 cases of Zika virus disease in Virginia residents to the CDC (2 in Northwest Region, 5 in Northern Region, 1 in Eastern Region, 3 in Central Region and 2 in Southwest Region). CDC has issued a travel alert (Level 2-Practice Enhanced Precautions) for people traveling to regions and certain countries where Zika virus transmission is ongoing. *Updated weekly. For Zika virus disease reporting, the week runs Thursday-Wednesday.

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Laboratory-confirmed Zika virus disease cases reported to ArboNET by state or territory — United States, 2015–2016 (as of April 27, 2016) http://www.cdc.gov/zika/geo/united-states.html StatesTravel-associated cases* No. (%) (N=426)Locally acquired cases† No. (%) (N=0)Alabama2 (<1)0 (0)Arizona1 (<1)0 (0)Arkansas2 (<1)0 (0)California29 (7)0 (0)Colorado2 (<1)0 (0)Connecticut1 (<1)0 (0)Delaware3 (1)0 (0)District of Columbia3 (1)0 (0)Florida90 (21)0 (0)Georgia13 (3)0 (0)Hawaii7 (2)0 (0)Illinois12 (3)0 (0)Indiana6 (2)0 (0)Iowa4 (1)0 (0)Kansas1 (<1)0 (0)Kentucky5 (1)0 (0)Louisiana4 (1)0 (0)Maine2 (<1)0 (0)Maryland11 (3)0 (0)Massachusetts7 (2)0 (0)Michigan3 (1)0 (0)Minnesota14 (3)0 (0)Mississippi3 (1)0 (0)Missouri3 (1)0 (0)Montana1 (<1)0 (0)Nebraska2 (<1)0 (0)Nevada2 (<1)0 (0)New Hampshire3 (1)0 (0)New Jersey9 (2)0 (0)New Mexico1 (<1)0 (0)New York77 (18)0 (0)North Carolina10 (2)0 (0)Ohio12 (3)0 (0)Oklahoma4 (1)0 (0)Oregon6 (2)0 (0)Pennsylvania16 (4)0 (0)Tennessee2 (<1)0 (0)Texas30 (8)0 (0)Utah2 (<1)0 (0)Vermont1 (<1)0 (0)Virginia12 (3)0 (0)

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Laboratory-confirmed Zika virus disease cases reported to ArboNET by state or territory — United States, 2015–2016 (as of April 27, 2016) http://www.cdc.gov/zika/geo/united-states.html StatesTravel-associated cases* No. (%) (N=426)Locally acquired cases† No. (%) (N=0)Alabama2 (<1)0 (0)Arizona1 (<1)0 (0)Arkansas2 (<1)0 (0)California29 (7)0 (0)Colorado2 (<1)0 (0)Connecticut1 (<1)0 (0)Delaware3 (1)0 (0)District of Columbia3 (1)0 (0)Florida90 (21)0 (0)Georgia13 (3)0 (0)Hawaii7 (2)0 (0)Illinois12 (3)0 (0)Indiana6 (2)0 (0)Iowa4 (1)0 (0)Kansas1 (<1)0 (0)Kentucky5 (1)0 (0)Louisiana4 (1)0 (0)Maine2 (<1)0 (0)Maryland11 (3)0 (0)Massachusetts7 (2)0 (0)Michigan3 (1)0 (0)Minnesota14 (3)0 (0)Mississippi3 (1)0 (0)Missouri3 (1)0 (0)Montana1 (<1)0 (0)Nebraska2 (<1)0 (0)Nevada2 (<1)0 (0)New Hampshire3 (1)0 (0)New Jersey9 (2)0 (0)

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Laboratory-confirmed Zika virus disease cases reported to ArboNET by state or territory — United States, 2015–2016 (as of April 27, 2016) http://www.cdc.gov/zika/geo/united-states.html StatesTravel-associated cases* No. (%) (N=426)Locally acquired cases† No. (%) (N=0)Alabama2 (<1)0 (0)Arizona1 (<1)0 (0)Arkansas2 (<1)0 (0)California29 (7)0 (0)Colorado2 (<1)0 (0)Connecticut1 (<1)0 (0)Delaware3 (1)0 (0)District of Columbia3 (1)0 (0)Florida90 (21)0 (0)Georgia13 (3)0 (0)Hawaii7 (2)0 (0)Illinois12 (3)0 (0)Indiana6 (2)0 (0)Iowa4 (1)0 (0)Kansas1 (<1)0 (0)Kentucky5 (1)0 (0)Louisiana4 (1)0 (0)Maine2 (<1)0 (0)Maryland11 (3)0 (0)Massachusetts7 (2)0 (0)Michigan3 (1)0 (0)Minnesota14 (3)0 (0)

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Maryland Confirmed Zika Virus Infections (As of April 27, 2016) Travel-AssociatedLocally Acquired Vector-BorneTotal12012 http://phpa.dhmh.maryland.gov/Pages/Zika.aspx

Maryland Confirmed Zika Virus Infections (As of April 27, 2016) Travel-AssociatedLocally Acquired Vector-BorneTotal12012

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Laboratory-confirmed Zika virus disease cases reported to ArboNET by state or territory — United States, 2015–2016 (as of April 27, 2016) http://www.cdc.gov/zika/geo/united-states.html StatesTravel-associated cases* No. (%) (N=426)Locally acquired cases† No. (%) (N=0)Alabama2 (<1)0 (0)Arizona1 (<1)0 (0)Arkansas2 (<1)0 (0)California29 (7)0 (0)Colorado2 (<1)0 (0)Connecticut1 (<1)0 (0)Delaware3 (1)0 (0)District of Columbia3 (1)0 (0)Florida90 (21)0 (0)Georgia13 (3)0 (0)Hawaii7 (2)0 (0)Illinois12 (3)0 (0)Indiana6 (2)0 (0)Iowa4 (1)0 (0)Kansas1 (<1)0 (0)Kentucky5 (1)0 (0)

As of April 27, 2016 (5 am EST) Zika virus disease and Zika virus congenital infection are nationally notifiable conditions.This update from the CDC Arboviral Disease Branch includes provisional data reported to ArboNET for January 1, 2015 – April 27, 2016.US States Travel-associated Zika virus disease cases reported: 426Locally acquired vector-borne cases reported: 0Total: 426Pregnant: 36Sexually transmitted: 8Guillain-Barré syndrome: 1US Territories Travel-associated cases reported: 3Locally acquired cases reported: 596Total: 599Pregnant: 56Guillain-Barré syndrome: 5 Laboratory-confirmed Zika virus disease cases reported to ArboNET by state or territory — United States, 2015–2016 (as of April 27, 2016) StatesTravel-associated cases* No. (%) (N=426)Locally acquired cases† No. (%) (N=0)Alabama2 (<1)0 (0)Arizona1 (<1)0 (0)Arkansas2 (<1)0 (0)California29 (7)0 (0)Colorado2 (<1)0 (0)Connecticut1 (<1)0 (0)Delaware3 (1)0 (0)District of Columbia3 (1)0 (0)Florida90 (21)0 (0)Georgia13 (3)0 (0)Hawaii7 (2)0 (0)Illinois12 (3)0 (0)Indiana6 (2)0 (0)Iowa4 (1)0 (0)Kansas1 (<1)0 (0)Kentucky5 (1)0 (0)Louisiana4 (1)0 (0)Maine2 (<1)0 (0)Maryland11 (3)0 (0)Massachusetts7 (2)0 (0)Michigan3 (1)0 (0)Minnesota14 (3)0 (0)Mississippi3 (1)0 (0)Missouri3 (1)0 (0)Montana1 (<1)0 (0)Nebraska2 (<1)0 (0)Nevada2 (<1)0 (0)New Hampshire3 (1)0 (0)New Jersey9 (2)0 (0)New Mexico1 (<1)0 (0)New York77 (18)0 (0)North Carolina10 (2)0 (0)Ohio12 (3)0 (0)Oklahoma4 (1)0 (0)Oregon6 (2)0 (0)Pennsylvania16 (4)0 (0)Tennessee2 (<1)0 (0)Texas30 (8)0 (0)Utah2 (<1)0 (0)Vermont1 (<1)0 (0)Virginia12 (3)0 (0)Washington2 (<1)0 (0)West Virginia6 (1)0 (0) Territories(N=3)(N=596)American Samoa0 (0)14 (2)Puerto Rico2 (67)570 (96)US Virgin Islands1 (33)12 (2)*Travelers returning from affected areas, their sexual contacts, or infants infected in utero †Presumed local mosquito-borne transmission Page last reviewed: February 4, 2016Page last updated: April 27, 2016

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As of April 27, 2016 there are no confirmed cases of Zika virus in South Carolina.

Confirmed Zika Cases in Oregon, 2016As of 4/26/2016 Travel-associated cases: 6 Oregon mosquito-acquired cases: 0 Total: 6

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At A Glance - Zika in the U.S.(as of Apr 26, 2016) North CarolinaTravel-associated Zika virus disease cases reported: 11Locally acquired vectorborne cases reported: 0 http://epi.publichealth.nc.gov/zika/

At A Glance - Zika in the U.S.(as of Apr 26, 2016) North CarolinaTravel-associated Zika virus disease cases reported: 11Locally acquired vectorborne cases reported: 0 U.S. StatesTravel-associated Zika virus disease cases reported: 388Locally acquired vectorborne cases reported: 0 U.S. TerritoriesTravel-associated cases reported: 3Locally acquired vectorborne cases reported: 500