Discussion: Congenital birth defects and the Zika virus

[Laidback Al]

Birth defects are a serious problem around the world. Every year an estimated 6% of the worldwide births (almost 8 million infants) suffer from some kind of birth defect. (link) According to the World Health Organization only 50% of congenital birth defects can be associated with a specific cause. (link) There is been little public concern about worldwide congenital defects the until recent media reports concerning the possible effects of the Zika virus on pregnant women from Brazil.

Sensationalistic media outlets have reported thousands of birth defects in Brazil as directly attributable to the Zika outbreak. These reports have raised international public concern but they have not been substantiated by national and international health agencies. As reported in several posts here, the link between the Zika virus and microcephaly in Brazil is still uncertain at this time. (link)

In the United States, we had extensive media hype about an Ebola epidemic when several imported Ebola cases were reported. It is disconcerting that once again, media and news organizations magnify public fears by jumping on the bandwagon about the Zika virus. Public officials appear to be catering to this hype and we are now seeing calls for an emergency program to develop a vaccine.

Certainly the Zika virus can have devastating effects, but overall the fatality rate is low and it is not transmitted from human to human. Of more concern are influenza viruses. Dr. Osterholm of the Center for Infectious Disease Research and Policy stated in a recent article

… Even more than these [other] viruses, we should be afraid of a planet-wide catastrophe caused by influenza. The best way to avert a pandemic is to develop a game-changing universal influenza vaccine.

link

When reading online information about infectious diseases you need to ask yourself several questions. Are these organizations and media outlets truly concerned about providing accurate scientific information about emerging diseases? Or is it more likely these organizations and outlets are trying to drive viewership and clicks to increase their revenue stream?

We are living in the Age of the Internet. We should always be concerned about the motivations surrounding the posts and webpages we read.

 

[Gert van der Hoek]

Agreed Al, however it is not easy to ignore news even if it could be biased. For instance MOH Colombia reports:" 20,297 cases of infection with the Zika virus, incl. 2,116 pregnant women"

It may be relevant or not relevant if pregnant women are infected with Zika. We don't know now. So I have to consider this information as relevant : at this moment.

 

[sharon sanders]

I generally completely ignore the main stream media in making any risk assessment. And that is what we are talking about here.

What is the risk that the microcephaly, Guillain?Barr? syndrome, and/or related conditions are caused by a Zika virus infection?

Well - at this point there is no proven cause and effect study or opinion piece that has been publicly released. There is some anecdotal evidence. For me important indicators are:

1) The Travel Advisory Alert Level 2 precautions updated by the CDC on January 26 for Central America, South America, and the Caribbean. link There are only 3 levels and rarely does the CDC issue a level 2 alert.

2) The Health Department of England (PHE) issued a guidance for men, even asymptomatic men, for sex after visiting Zika affected countries. The PHE is asking all men to use condoms for 28 days after they return and to use condoms for 6 months if they have experienced any possible Zika symptoms. link This type guidance is unprecedented for merely visiting a country.

3) The Brazil Ministry of Health press release confirming the relationship between Zika virus and microcephly dated November 28, 2015. link

4) Several countries in Central and South America have asked their citizens to delay pregnancies. I have never seen this before: Jamaica link , Colombia link , Dominican Republic link , Brazil link , El Salvador link





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[Laidback Al]

Agreed Al, however it is not easy to ignore news even if it could be biased. For instance MOH Colombia reports:" 20,297 cases of infection with the Zika virus, incl. 2,116 pregnant women"

It may be relevant or not relevant if pregnant women are infected with Zika. We don't know now. So I have to consider this information as relevant : at this moment.

Gert, there is no doubt that pregnant women are being infected with the Zika virus. The epidemiological question is whether or not statistically more cases of microcephaly are occurring among births from these infected women compared to pregnant women who are not infected. From post 2 in the thread you mentioned is the following

... Some 560 pregnant women are among those infected, the minister said, though so far no cases of newborns suffering from microcephaly, a congenital defect caused by zika, have been registered in the country. . .

 

[Laidback Al]

In order to help people evaluate the indicators that Sharon Sanders posted above I? have expanded on each of them below.

1) The Travel Advisory Alert Level 2 precautions updated by the CDC on January 26 for Central America, South America, and the Caribbean. link There are only 3 levels and rarely does the CDC issue a level 2 alert.

It is doubtful that the CDC has much more information than is publicly available at this time. I interpret this travel advisory from the CDC as a CYA precaution. It is simply good politics to raise a travel alert as public interest swells in this disease outbreak.

2) The Health Department of England (PHE) issued a guidance for men, even asymptomatic men, for sex after visiting Zika affected countries. The PHE is asking all men to use condoms for 28 days after they return and to use condoms for 6 months if they have experienced any possible Zika symptoms. link This type guidance is unprecedented for merely visiting a country.

Safe sex is good practice everywhere. In this NY times article, the two confirmed cases of sexual transmission of Zika are profiled.

Two suspect cases ?are not really enough to warrant a large public health recommendation from the C.D.C.,? he said. ?But it?s provocative, so someone else could recommend it. And it certainly should be studied.?

link

In the case of Zika virus, and other arboviruses as well, people should be very concerned about contracting the disease through mosquito bites. Although there is scientific evidence that the Zika virus can be transmitted through semen, I see this as another example of a public health agency being overly cautious.

3) The Brazil Ministry of Health press release confirming the relationship between Zika virus and microcephaly dated November 28, 2015. link

In another thread I have posted a timeline of press reports from the Brazil Ministry of Health. link In reviewing the timeline, it appears that through late January there are perhaps 6 to 10 cases of microcephaly associated with laboratory confirmation of the Zika of virus in Brazil. Six cases are insufficient to establish causality.

From January 28, 2016

. . . Although the Brazilian government has said there are almost 4,000 cases of microcephaly in the country, only six of the cases have been strongly linked to Zika virus via laboratory testing that confirms genetic material from the virus is present in the infant, Claudio Maierovitch, director of the Department of Communicable Disease Surveillance in Brazil?s Ministry of Health told the WHO today in Geneva. Brazilian officials with assistance from the CDC and other groups are now trying to firm up that data. . . .

link

The correlation of increases in microcephaly with increases in the Zika virus infections in Brazil is simply a correlation until a causal relationship is established. It is not even certain if there are actual year-over-year increases in microcephaly in Brazil. We need to be critical of the past data on microcephaly in Brazil. A CDC epidemiologist comments:

? In 2014, only about 150 cases were reported in Brazil in a year ? a surprisingly small amount for a large country with nearly 3 million births a year. The United States, with about 4 million births a year, has an estimated 2,500 cases of microcephaly a year, said Margaret Honein, a CDC epidemiologist?

link

Based on the birth rate, Brazil should be reporting thousands of cases of microcephaly a year regardless of their cause.

4) Several countries in Central and South America have asked their citizens to delay pregnancies. I have never seen this before: Jamaica link , Colombia link , Dominican Republic link , Brazil link , El Salvador link

The World Health Organization has not issued any statement recommending that women avoid pregnancy for fear of infection by the Zika virus. The earliest reports I could find recommending the delay of pregnancy are from media reports from Brazil from last December.

Two different individuals from Brazil, as noted in the quotes below, recommended delaying pregnancy for residents in areas where there was a high frequency of Zika infections. However as noted by Maierovitch, this is not an official policy by the Brazilian Ministry of Health.

Though it is not official policy, Cl?udio Maierovitch, the director of the communicable disease surveillance department at the ministry of health, has advised women in high-risk areas to avoid attempting to conceive.
?Don?t get pregnant at the moment,? he said. ?That?s the wisest course of action.?

http://www.theguardian.com/global-de...e-birth-defect

"It's a very personal decision, but at this moment of uncertainty, if families can put off their pregnancy plans, that's what we're recommending," Angela Rocha, the pediatric infectologist at Oswaldo Cruz Hospital in Brazil's hardest-hit state, told CNN.

http://www.cnn.com/2015/12/23/health...nancy-warning/

The other countries in Sharon?s list all appeared to have jump on the media bandwagon in January regarding recommendations for delaying pregnancy. After all, no country wants to be seen as callous towards pregnant women and expectant mothers.

Having a child is a very personal decision. Every woman contemplating pregnancy needs to be presented with the risks and the alternatives in an unbiased manner in order to make an informed choice.

 

[sharon sanders]

So what you are basically saying is that the governments of: England, United States, Brazil, Jamaica, El Salvador, Columbia, and the Dominican Republic have over-reacted in the absence of hard proof that the reported cases of microencephaly and related ills are caused by maternal Zika infections?

From the French government:

snip

"In French Polynesia, cases of embryofœtopathies also coincide with the period
probable Zika virus circulation. In 15 cases, at least a portion of the first six months of
pregnancy took place during the epidemic period.

At least three mothers reported a Zika type of episode during pregnancy, but others

Investigations are ongoing. All mothers had received a serological balance
pregnancy and no cases of CMV or rubella infection was detected. In addition, the 13 results
Available realized karyotypes were normal.

snip

In summary, major judged causal criteria are met: strength of association,
consistency and temporality. This is in favor of the causal infection Zika in
occurrence of cases malformations. However, further studies, pathophysiological
in particular, is needed to definitively establish causality.

Conclusion
The relation of cause and effect between cases of resurgence of fetal or neonatal microcephaly
and Zika virus infection in the mother during pregnancy is not, at this
day formally established. However, this assumption is likely, should be taken as soon
now and in the pending confirmation or reversal, a number of
measures. These measures are to be taken in the context of and severity of microcephaly
extension of the disease."

file:///C:/Users/pcowner/Downloads/hcspa20160105_zikaactualisationmodpec%20(1).pdf


-------------------------------------------------

I agree that an informed public is an empowered public.


hat tip to Pathfinder for the French government link and translation.

 

[Laidback Al]

In this Age of the Internet, government health agencies must consider the pulse of public sentiment when making decisions. What I am saying is that the confusing data from Brazil does not support the media hype we have seen.

Under the current conditions and with the current lack of more detailed scientific information, the responses we are seeing from the various government agencies are the only possible, appropriate reactions.

 

[Pathfinder]

Twitter Alert from WHO
​

​

​

​

WHO ‏@WHO 25m25 minutes ago
WHO Director-General Dr Margaret Chan: #ZikaVirus & #microcephaly situation is a Public Health Emergency of Intl Concern #alert

https://twitter.com/WHO?ref_src=twsrc^google|twcamp^serp|twgr^author
​

​

​

​

 

[Emily]

But the link is still not proven according to other tweets.





WHO Verified account ‏@WHO

Dr Heymann emphasized vector control, surveillance, R&D for vaccines & other goods needed to control #Zika if link w/#microcephaly is proven
WHO Verified account ‏@WHO


Dr Heymann: Not known how long it will take to find link between #ZikaVirus and #Microcephaly

 

[Pathfinder]

"Margaret Chan, WHO Director-General, said at a press briefing that the primary reason for the decision was that members of an 18-member advisory panel agree that a causal relationship between Zika and microcephaly is "strongly suspected" although it hasn't been scientifically proven. She said that given the seriousness of the conditions being reported, the consequences of waiting were too great.

“Even the clusters of microcephaly alone are enough to declare a public health emergency because of its heavy burden" on women, families, and the community, Chan said."

https://www.washingtonpost.com/news/...d-in-americas/
------------------------------------------------------------------------------------------------------------------------------

"Doctors in the Centros said they are at “breaking point” under the enormity of the crisis as the disease continued to grips South America.

Some parents have been left having nervous breakdowns due to the stress of caring for their affected baby with one mum abandoning her child at the doors of a hospital unable to cope.
...
Bosses at the clinic say they need more than 7,000 extra doctors just to deal with the epidemic in Brazil.

Speaking to the Mirror Dr Liana Ventura, the president of the clinic - a specialist unit to treat diseases - spoke about the size of the problem now facing her country.

She said: “Throughout Brazil there are thousands of cases. There is no end in sight.

“We need help and we need it now. We are drowning in the amount of cases we are now treating."
...
http://www.mirror.co.uk/news/world-n...vealed-7289006

 

[Emily]

This tweet from a couple posts above indicates confirmation bias:

Dr Heymann: Not known how long it will take to find link between #ZikaVirus and #Microcephaly

I don't have any confidence if that is the approach to investigating whether there is birth defect cluster in the first place and if there is, what is causing it?

 

[Dani]

"Margaret Chan, WHO Director-General, said at a press briefing that the primary reason for the decision was that members of an 18-member advisory panel agree that a causal relationship between Zika and microcephaly is "strongly suspected" although it hasn't been scientifically proven. She said that given the seriousness of the conditions being reported, the consequences of waiting were too great.

“Even the clusters of microcephaly alone are enough to declare a public health emergency because of its heavy burden" on women, families, and the community, Chan said."

https://www.washingtonpost.com/news/...d-in-americas/
------------------------------------------------------------------------------------------------------------------------------

"Doctors in the Centros said they are at “breaking point” under the enormity of the crisis as the disease continued to grips South America.

Some parents have been left having nervous breakdowns due to the stress of caring for their affected baby with one mum abandoning her child at the doors of a hospital unable to cope.
...
Bosses at the clinic say they need more than 7,000 extra doctors just to deal with the epidemic in Brazil.

Speaking to the Mirror Dr Liana Ventura, the president of the clinic - a specialist unit to treat diseases - spoke about the size of the problem now facing her country.

She said: “Throughout Brazil there are thousands of cases. There is no end in sight.

“We need help and we need it now. We are drowning in the amount of cases we are now treating."
...
http://www.mirror.co.uk/news/world-n...vealed-7289006

Hello,
I have not posted here for a while, but some of you may remember me. My background is in hospital administration and clinical medicine. I am an OB/GYN by training.

While the above observations are anecdotal, they are striking. An obstetrician may go his or her entire career and never deliver an infant with microcephaly. For me to see six of them in one photo is nothing short of chilling.

So I'm in agreement with the perhaps overly cautious approach taken by the governments noted above, for several reasons. First, the prenatal diagnosis of microcephaly is not straightforward as it is a variation of normal and depends on how many standard deviations below the mean one decides to use to diagnose it. Even at -3 SD the number of false positive can reach as high as 50%. Improving the sensitivity and specificity of prenatal screening is an ongoing area of active research even now.

Furthermore, even accurate prenatal diagnosis is unlikely to change the number of microcephalic births. There has been quite a bit of media coverage regarding the restrictions on abortion in some of these countries, but I believe the press getting bit ahead of itself with that topic, as the diagnosis is generally made late in pregnancy when abortion is no longer an option. However, because virtually nothing is known about the prenatal course of Zika virus disease, there may be other markers for fetal infection of which we are unaware that may be picked up earlier.

We don't even know what percentage of babies born to infected mothers are infected themselves. Without that knowledge, counseling regarding termination before fetal diagnosis is terribly fraught with uncertainty. No woman can give informed consent, because there is no information. Given all of these unknowns, the guilt and fear on the part of the parents would be enormous. I've certainly seen this when the diagnosis is known- imagine if it's only a "what if".

Because of the inability to detect, treat, or even terminate affected fetuses I am strongly in favor of applying the precautionary principle in this situation. Having a child with a severe mental handicap is devastating to a parent, even in wealthy countries with the resources to support such families.

 

[sharon sanders]

Welcome back Dani.


The CDC has added several countries to it's health advisory list. link. Today Florida declared a medical emergency in 4 counties, including some of the most populous areas of the state. link

 

[Pathfinder]

Source:
http://www.cngof.fr/briefcase/Presse...ka%20CNPGO.pdf (61 pages)

Translation Google

France - National Professional Council of Obstetrics and Gynecology

Temporary Document information,
for health professionals.
Version 1.2 of February 2, 2016
capable of real-time update
virus ZIKA
And pregnant or age
of childbearing

...
A pregnant woman exposed to the virus ZIKA the first or second trimester of
pregnancy would have a theoretical risk of having a child microcephalic estimated between 0.1% and
16%. However, these figures from reports issued in Brazil could be specified
in the following weeks.
...

On 30 November 2015 it was recorded 1248 cases and 2700 cases in December 2015 (99.7 cases / 100
000 live births).

Meanwhile, it was recorded between 500 000 and 1.5 million cases of virus infections ZIKA in
2015 in the country with an increase in late 2015.

Thus, to 2.9 million pregnancies in Brazil, the incidence of microcephaly for
the epidemic would be about 0.1% of births. But if we compare the number of cases of people
infected with the virus in 2015 ZIKA the total Brazilian population and that we apply this
penetration in the population of pregnant women, about 21,750 pregnant women could have been
infected in Brazil. The incidence of microcephaly in case of infection by the virus ZIKA
could then be close to 16%, provided that microcephaly has not been over-declared
from doctors, and provided that the number of people infected is
spread evenly throughout Brazil. The maternal-fetal transmission rate is not
known to date.

Thus, asymptomatic pregnant patient which can not prove that she was infected at
the first or second quarter, and return from an endemic country such as Brazil, could have a
risk of having a child microcephalic between 0.1% and 16%.

It is important to await the outcome of the ongoing investigation into the reality of microcephaly
reported in Brazil, especially since the Brazilian medical community has been sensitized to report
cranial perimeter of birth less than 32 cm at birth instead of 33 cm. This impact
very well could be revised downward, some children with just a variant of normal.

The concentration of cases of ZIKA virus on some Brazilian regions is also a
factor that hinders the quantification of the actual incidence of microcephaly in case of infection of
pregnant women with the virus ZIKA and requires great caution in interpreting these alerts urgently.
...

 

[Emily]

Hello,
I have not posted here for a while, but some of you may remember me. My background is in hospital administration and clinical medicine. I am an OB/GYN by training.

While the above observations are anecdotal, they are striking. An obstetrician may go his or her entire career and never deliver an infant with microcephaly. For me to see six of them in one photo is nothing short of chilling.

So I'm in agreement with the perhaps overly cautious approach taken by the governments noted above, for several reasons. First, the prenatal diagnosis of microcephaly is not straightforward as it is a variation of normal and depends on how many standard deviations below the mean one decides to use to diagnose it. Even at -3 SD the number of false positive can reach as high as 50%. Improving the sensitivity and specificity of prenatal screening is an ongoing area of active research even now.

Furthermore, even accurate prenatal diagnosis is unlikely to change the number of microcephalic births. There has been quite a bit of media coverage regarding the restrictions on abortion in some of these countries, but I believe the press getting bit ahead of itself with that topic, as the diagnosis is generally made late in pregnancy when abortion is no longer an option. However, because virtually nothing is known about the prenatal course of Zika virus disease, there may be other markers for fetal infection of which we are unaware that may be picked up earlier.

We don't even know what percentage of babies born to infected mothers are infected themselves. Without that knowledge, counseling regarding termination before fetal diagnosis is terribly fraught with uncertainty. No woman can give informed consent, because there is no information. Given all of these unknowns, the guilt and fear on the part of the parents would be enormous. I've certainly seen this when the diagnosis is known- imagine if it's only a "what if".

Because of the inability to detect, treat, or even terminate affected fetuses I am strongly in favor of applying the precautionary principle in this situation. Having a child with a severe mental handicap is devastating to a parent, even in wealthy countries with the resources to support such families.

Welcome back, Dani, and thanks very much for commenting. I can understand your concern about how families here deal with some birth defects. Many in the US live in a culture of brittle perfectionism, blind ambition and greed, (or they are at the other end of the spectrum.) People here can be poorer in spirit than those in countries with lower GDP's. Just look at the clusters of teen suicides in some affluent communities and self-destruction through drug use by beautiful, 'perfect' kids. I'm sure there is good reason for all of it. Mother Teresa said there was what she called a 'poverty of isolation' in the US that made her sadder than the worst poverty she saw in India.

People in Brazil do have another big advantage over the US in dealing with medical challenges - out of pocket medical costs are lower. Tetano found a wonderful article about a young woman journalist there who was born with microencephaly. She had many operations and had seizures that somehow resolved as she grew. Her extended family helped her parents with significant bills that were not covered by insurance. She went to university and has a good life that she values and is disturbed at the world's reaction to disabled children.

Hey, even in some parts of the US families and communities are doing a fine job of embracing severe disabilities in children. I saw this article about a family in Kansas with 2 daughters with microcephaly. However in WA state, there is a large cluster of neural tube defects that is pretty much ignored by the CDC and has had a lackluster response from the state. (They did not even manage to get folic acid supplements delivered to women in this ongoing event, let alone figure out what is going on. No virus scare = no money.)

I do think there is a cluster in Brazil and it needs to be investigated properly, but the true, new cluster with the unique and severe disabilities is a lot smaller than the media is saying.

 

[sharon sanders]

Welcome back, Dani, and thanks very much for commenting. I can understand your concern about how families here deal with some birth defects. Many in the US live in a culture of brittle perfectionism, blind ambition and greed, (or they are at the other end of the spectrum.) People here can be poorer in spirit than those in countries with lower GDP's. Just look at the clusters of teen suicides in some affluent communities and self-destruction through drug use by beautiful, 'perfect' kids. I'm sure there is good reason for all of it. Mother Teresa said there was what she called a 'poverty of isolation' in the US that made her sadder than the worst poverty she saw in India.

People in Brazil do have another big advantage over the US in dealing with medical challenges - out of pocket medical costs are lower. Tetano found a wonderful article about a young woman journalist there who was born with microencephaly. She had many operations and had seizures that somehow resolved as she grew. Her extended family helped her parents with significant bills that were not covered by insurance. She went to university and has a good life that she values and is disturbed at the world's reaction to disabled children.

Hey, even in some parts of the US families and communities are doing a fine job of embracing severe disabilities in children. I saw this article about a family in Kansas with 2 daughters with microcephaly. However in WA state, there is a large cluster of neural tube defects that is pretty much ignored by the CDC and has had a lackluster response from the state. (They did not even manage to get folic acid supplements delivered to women in this ongoing event, let alone figure out what is going on. No virus scare = no money.)

I do think there is a cluster in Brazil and it needs to be investigated properly, but the true, new cluster with the unique and severe disabilities is a lot smaller than the media is saying.

So you suspect this Zika virus/Guillian-Barre/microcephaly situation is a virus scare to generate cash flow into pharma and related industries?

 

[bertrand789]

en langue de Moli?re:

http://lesmoutonsenrages.fr/2016/02...un-virus-banal-en-menace-mondiale/#more-91811

 

[Emily]

So you suspect this Zika virus/Guillian-Barre/microcephaly situation is a virus scare to generate cash flow into pharma and related industries?

Absolutely not, Sharon! My point was that basic independent research is seriously underfunded in this country. I've only seen credible allegations of disease-mongering afoot in the chronic disease realm:
http://www.bmj.com/content/324/7342/886.1

Within many disease categories informal alliances have emerged, comprising drug company staff, doctors, and consumer groups. Ostensibly engaged in raising public awareness about underdiagnosed and undertreated problems, these alliances tend to promote a view of their particular condition as widespread, serious, and treatable.

A post of mine in another thread somehow got deleted where I shared that I agreed with CDC in their assessment at the time that Zika would not pose a threat to the US. I don't think they are hyping this virus just as they did not hype Ebola's threat to the US. (And they were right about that basically. They just overestimated the handling ability of average US hospitals.) Also I said I agree with the precautionary principle in their travel advisory for pregnant women.

On the other hand, confirmation bias is a fact of human existence and has nothing to with insincerity or bad character and it does not mean someone is ultimately wrong in their hypothesis. The doctors in NW Brazil that noticed the uptick in unusual microcephaly cases have been totally forthcoming.

http://nymag.com/thecut/2016/02/brazilian-doctor-connected-zika-to-birth-defects.html
http://www.wsj.com/articles/the-bra...ded-alarm-on-zika-and-microcephaly-1454109620

Then there was this: In a typical year, the doctors said, they might see one microcephaly case every couple of months. Suddenly, they were seeing dozens.

So that shows that NW Brazil had a high baseline of microcephaly to begin with. Dani shared that an obstetrician can go an entire career here in the US without ever delivering one baby with microcephaly, yet 2,500 cases were reported and only 150 were reported in Brazil prior to the Zika outbreak?

http://www.usnews.com/news/world/ar...e-research-needed-into-zika-microcephaly-link

The release of new figures apparently finding fewer cases of microcephaly in Brazil than first feared is leading to calls for more research into the link between the rare birth defect and the Zika virus
By JENNY BARCHFIELD and MIKE STOBBE, Associated Press
...
In 2014, only about 150 cases were reported in Brazil in a year ? a surprisingly small amount for a large country with nearly 3 million births a year. The United States, with about 4 million births a year, has an estimated 2,500 cases of microcephaly a year, said Margaret Honein, a CDC epidemiologist.

 

[sharon sanders]

A post of mine in another thread somehow got deleted where I shared that I agreed with CDC in their assessment at the time that Zika would not pose a threat to the US. I don't think they are hyping this virus just as they did not hype Ebola's threat to the US.

Nothing was deleted. Several posts (including mine) from 1 thread were moved to the archive.

 

[Dani]

Welcome back, Dani, and thanks very much for commenting. I can understand your concern about how families here deal with some birth defects. Many in the US live in a culture of brittle perfectionism, blind ambition and greed, (or they are at the other end of the spectrum.) People here can be poorer in spirit than those in countries with lower GDP's. Just look at the clusters of teen suicides in some affluent communities and self-destruction through drug use by beautiful, 'perfect' kids. I'm sure there is good reason for all of it. Mother Teresa said there was what she called a 'poverty of isolation' in the US that made her sadder than the worst poverty she saw in India.

People in Brazil do have another big advantage over the US in dealing with medical challenges - out of pocket medical costs are lower. Tetano found a wonderful article about a young woman journalist there who was born with microencephaly. She had many operations and had seizures that somehow resolved as she grew. Her extended family helped her parents with significant bills that were not covered by insurance. She went to university and has a good life that she values and is disturbed at the world's reaction to disabled children.

Hey, even in some parts of the US families and communities are doing a fine job of embracing severe disabilities in children. I saw this article about a family in Kansas with 2 daughters with microcephaly. However in WA state, there is a large cluster of neural tube defects that is pretty much ignored by the CDC and has had a lackluster response from the state. (They did not even manage to get folic acid supplements delivered to women in this ongoing event, let alone figure out what is going on. No virus scare = no money.)

I do think there is a cluster in Brazil and it needs to be investigated properly, but the true, new cluster with the unique and severe disabilities is a lot smaller than the media is saying.

I think that's a very good point about the strength of the family & social structure in the affected countries. That's another reason why I think the news media is getting ahead of itself regarding focusing on the abortion laws. They're imposing their beliefs of what needs to occur in this situation. These are, for the most part, representative governments from what I understand. So the laws, generally, will reflect the beliefs of the people there. They may be more accepting of birth defects of all kinds. Certainly it is that way in the part of the US where I practice.

However, I must take issue with the article in the BBC about the young lady with an excellent outcome following neonatal microcephaly. The young lady in the article does not appear to have had the Zika type of developmental microcephaly, where the skull is small because the brain is. There are many cranial fusion disorders that cause a child to have a small skull, and it sounds like that's what she had. Her brain was normal and just needed room to grow, and surgery was needed to accomplish that, which she did mention that she had. Surgery is of no use in microcephaly due to an underdeveloped brain. That is the tip-off that she did not, in fact, have the type of microcephaly associated with the Zika virus.