Thursday, February 4, 2016

Zika virus infection 2015-16 Epidemic - Update #1

Zika virus infection 2015-16 Epidemic
January 2016 Update
Paul Herscu, ND, MPH
Herscu Laboratory

We have just passed over a milestone that I want to highlight, to place the discussion about Zika virus in a very important context. We have just had a twelfth case of Zika virus infection diagnosed in the USA. This number is significant to me, since it is exactly one more patient than the total number of Ebola virus disease (EVD) patients to have hit USA soil from the Ebolavirus 2014 Outbreak in Western Africa. That number includes those who developed EVD in Africa and were transported here and those who fell ill from human transmission inside the USA.
I believe it is of upmost importance to place any discussion of Zika virus infection within an EVD context for a variety of reasons. When I commented on EVD, both in this Blog  and in the Webinar I presented on Viruses, I made some very strong comments and predictions. These were based on tracking viral infection outbreaks and epidemics around the worlds for several decades.
One point I highlighted was as we look at the history of our species and its effect on other species on this planet one thing becomes clear. As we have explored, conquered, inhabited and thrived in a variety of environments around the planet, when we found a species that was large-toothed, venomous, and scary, we would try to destroy it, driving the species towards extinction. We feel more comfortable when they are not threatening us. Right or wrong this is what we have done. And as we have begun to feel more comfortable in our surroundings, we began to look more closely at what may be the new scary things to our species–germs, bacteria and viruses. And as our technology has gotten better, cheaper, more accurate and specific, we are better able to isolate an ever-increasing diverse microcosm, both outside and inside of our bodies. In short, we have relearned that we are not alone. And again, reflexively, we are frightened. An added fear is the continued realization that an ever-larger number of bacteria become scarier as we encourage their evolution with and toward antibiotic resistance.

To put it in context, 25,000 people will die in Europe, a fifth of that number in the UK, from antibiotic resistant bacteria that we already know and have known of for decades and have been treating with antibiotics. This leaves out the other compelling statistic: 30,000 people who are going to die of the seasonal influenza in the USA this year.
I also wrote about a second, related, point. While there are a large number of germs dangerous to us and even lethal, many were found in isolated villages. With increased travel, germs are emerging from the villages, as our species becomes more integrated within a more crowded planet. Little virus clusters that would kill the group of hosts, in an isolated village now become more likely to reach epidemic proportion, as we found with EVD. As I mentioned, EVD is not the first and will not be the last to reach headline status. Oddly, even though we already know this, and perhaps because we know it, the fact that so many will die from germs that we have always known, like influenza, does not seem to reach headline status.
A third important point. We have been focusing on acute germs. However, let’s look at chronic viral issues for a moment. There are any number of viruses and post viral/germ situations that settle into chronic form in humans: Herpes, Hepatitis C, Lyme and other tickborne Diseases, Chronic Fatigue Syndrome, HIV, and many others. And in this year, 2016, many more people will suffer and die from these than any acute epidemic that you are currently concerned about.
A fourth important point. We know that many autoimmune diseases begin with or are triggered by viral and infectious diseases, be it MS, ITP, or kidney/thyroid diseases. Many more will suffer and die from these immune mediated diseases than of the infection that grabs the spotlight right now.
Why am I bringing up this chronic infection fact? Our species is pretty good at developing tools that deal with whatever we perceive as threatening. We had good tools to kill the big threatening species, and once we began to focus on bacteria got pretty good at killing those. We are however, running out of playing this game. We are trying to learn a new way of being, of coexisting with certain germs, modifying ourselves to deal with germs. And in the meantime, we are just now, at the cusp of a change in philosophical/scientific/medical thought. We are just now starting to see ourselves as needing to integrate within the species around us and in us rather than kill them all. There is no ‘us’ without the germs around us. This has become scientific fact, but it takes time to percolate down to clinical practice and the general public. Specifically, while we are now looking for tools that kill viruses, we are also looking at controls and balance. But first let me share a bit about the viral kills we are looking for.
Realizing that there is a great deal of commonality within viruses, we are looking at mechanisms to kill viruses, which is somewhat novel for chronic viral infections in humans. Hepatitis C, something that was supposed to be permanent and lifelong, once contracted can be removed with new drugs. I believe HIV will also be gotten rid of, not just controlled. And as this is underway, finding cures for chronic tickborne illnesses, herpes, CFS, EBV, etc., will not be far behind. And after that we will be curing, not strictly controlling autoimmune disease, and even a related topic, certain cancers.
Here is why I mention these points. It is a very hard sell to encourage the general population to fund research on chronic viral infections, though millions suffer from such ailments. It is hard to fund influenza research or even to, in some medical circles, admit the existence of chronic tickborne illnesses. It simply does not grab headlines, when many people are trying to find a job or feed their families. Even though scores of thousands will die from these every year. In contrast, it is easy to grab headlines with a new threatening germ.
Which brings me to the main point: All research on EVD, or research on Zika virus infection, all breakthroughs, are going to help us understand viruses better and in this way, help us race towards a better understanding of how to deal with all of them. With this in mind, think of current germs as scary to one extent or another, but really the energy, money, and focus that governments are going to give, will also fund viral research that would not otherwise be funded. As I mentioned before, I have no doubt that years from now when there are cures for different chronic viral infections, some of that research will have originated in EVD, Zika virus infection research, amongst other similar scary viruses.
Lastly, before we start to discuss this specific virus, I want to ask you to consider doing one thing for me. Please read the blog posts on EVD that I posted starting in September 2014. I want to underscore one thing here. In September 2014, when the medical community, scientists, governments predicted all sorts of horrific outcomes with EVD, I posted that the cumulative death count will fall somewhere between 10,000 and 30,000, with the number being closer to 10,000 if we did most things right enough. 15 months later, as of now, the case count for EVD in western Africa stands at 28,602 and cumulative deaths at 11,301, and as well, 11 in the USA, matching what I wrote that I thought few if any cases would be reported in the USA. This is highly accurate to my prediction, given the crazy news and predictions. Read the blog posts on EVD; it will help you place the Zika virus infection discussion in context.
Since 1997, but especially after 9/11, the US government with CDC and other international agencies, began to more carefully catalogue and track biological agents that might be employed in bioterrorism or had a high level of potential harm if epidemic infection rates were reached. These were ‘Select Agents’, and on that list, viruses such as Ebolavirus was a Tier 1 agent, meaning it was classified as an emerging potential threat for a widespread epidemic, with easy communicability, low infectious dose (just a few virions are enough to cause illness), and potential weaponization of the infectious agent. At this time Zika virus is not on that list but I can easily imagine it might be added to the list.
The CDC had it right. If you would like to see the list and further information, here are the links:
Flaviviridae  Family
The Zika virus belongs to the Flaviviridae Family, though not assigned to an Order. While we do not know much about this virus, we do know a great deal about related viruses, so we should discuss them all, to place Zika virus in context. 
This Family is organized into four major Genera, Flavivirus, Hepatocivirus, Pegivirus, and Pestivirus. The last Genus contains bovine viral diarrhea virus 1 (speaks for itself), Hepacivirus contains Hepatitis C virus (speaks for itself), Pegivirus causes several diseases not common at this time, causing hepatitis. But by far the most number of species reside in the Flavivirus Genus. It is in the Flavivirus Genus that Zika virus resides, as do other notable agents, such as West Nile Virus, Yellow Fever virus, tickborne encephalitis virus, dengue fever virus, alongside many others found throughout the world, including new ones in Brazil. Just in case Americans feel left out there is always the St. Louis encephalitis virus which was reported as far Northeast as New York, as far South as Texas, and as far Northwest as Washington, though you probably never heard of it, and it probably did not make headlines in your local paper. If you want to see a more complete list of members in this Family looks like go to this link:
We have known this Family and genus and some of these viruses for a long time. For the most part, though, we did not care about many of them, until we started to identify more and more of them with the new cheaper technologies. In fact, the number of species in this Family has exploded in the last couple of years. There is no reason to believe that this will not continue as we discover more and more of these viruses.
In the Flaviviridae Family, viruses are single stranded and small (like EVD is), but they are positive sense RNA. RNA viruses have RNA as their genetic material and can be single or double stranded; Zika virus is single stranded. I believe the family name ‘Flaviviridae‘ refers to the fact that one of the viruses in this family causes yellow fever where many people become jaundiced, and in Latin flavus means yellow, therefore ‘yellow viruses’ gets the point across well enough. It follows that for instance, Yellow Fever Virus causes yellow fever.
Here is what I wrote in the EVD first blog as relating to Zika virus: Single stranded RNA viruses are further separated into possessing positive, negative and ambisense polarity. Positive sense viruses, such as Zika virus are known as Group IV in the Baltimore Classification, and therefore very similar to the host’s mRNA. Because of this, the human ribosome directly translates the genetic material as if it were part of a human cell, making protein. Examples of positive sense RNA viruses include SARS, West Nile Virus, Dengue virus, and Poliovirus, an auspicious and challenging group of viruses by any estimation. Zika virus fits here as well, and is different from negative sense viruses, such as Ebolavirus (Group V), which are complementary to the host cell’s mRNA. This viral genetic material must go through a change, it must be transcribed into several positive sense RNA using a RNA-dependent RNA polymerase in order to turn into a positive sense RNA. They then act similar enough to the above positive sense RNA virus. Examples of negative sense RNA viruses include Ebolavirus, Marburgvirus, Rabies virus, and Crimean-Congo hemorrhagic fever virus, an equally difficult group of viruses with which humans interface. Just to round out the dangerous viruses, there are some single stranded RNA positive sense viruses that eventually need a DNA phase to complete their cycle, called Retroviruses, that are also threatening. HIV-1 and HIV-2, the viruses causing AIDS fit here. A list of viruses separated by Baltimore’s virus classification method that groups viruses into families based on their genome and replication method, can be found by clicking below:
Zika virus Infection
With that in mind, here is a very short history of our understanding of Zika virus infection. As an experiment to better understand Yellow Fever, a monkey was left outside to the elements in the Zika forest near Entebbe, Uganda, a property of the Uganda Virus Research Institute. The monkey became ill, and in 1952 the virus was isolated and described and became known as Zika virus. Interestingly, this is also when Entebbe bat virus, a very similar virus to Zika virus, was isolated and recorded the same decade, and then was only rarely found until 2011.  (The reason I mention Yellow fever and Entebbe bat virus is that they are both in the same Family as Zika virus, and this is how we learn of the ever-complex rich world we live in, which includes many, many viruses we never knew about.)
Zika virus was found locally there and began to spread, eventually to some island countries in the Pacific, before reaching South America. It hit Brazil in particular before spreading through South and Central America. It has also been found in travelers from many countries returning from impacted areas. In all respects, Zika virus should spread to a much, much larger number of people and much more quickly than EVD did in 2014-2015. Here are the reasons why:
Mode of transmission. EVD is transmitted by direct transmission, either person to person, cadaver to person, or bodily fluids to person.  As such you had to be close to another ill person in order to be infected. That is not the case with Zika virus. Unfortunately, here, the virus is classified as an arbovirus, that is, being passed by being bitten by an infected daytime mosquito, genus Aedes. That is the primary mode of transmission, though it may be passed through sexual contact as well as through the placenta of a pregnant woman to reach the fetus. The fact that transmission is by a bug makes spread imminently more likely than EVD. At the very least, wherever this mosquito is found there is the possibility of the spread of Zika virus. More on this below.
Man-made borders mean little. Since we are dealing with mosquitoes that do not respect geographical borders, national programs will not limit spread. Regional plans need to be enacted which takes time to put in place, time that allows further spread.
It may be relatively new to many populations. Many times when a virus infects a population that has not dealt with it before there are many casualties, as both species learn to adapt to each other.
Symptoms mimicry. Many of the symptoms, as described below, mimic other viral infections, making diagnosis tricky.
Symptoms of Zika virus infection
One very important point to start. Most people infected with the virus will not develop symptoms, which I address below. However, if they do develop symptoms, the most common ones are: fever, muscle and joint pains, headaches, conjunctivitis and a rash. Mostly, people who develop symptoms will stay home to recover, as if they have a cold or influenza, or dengue fever or chikungunya. More severe symptoms of the bitten person are rare but happen. The virus remains in the blood for several days to a week and if a subsequent mosquito bites the infected person, the cycle continues as mosquitoes pass it on to the next person bitten.
Approved Treatment
At this time, treatment of ill patients is similar to common sense symptomatic treatment at home and is primarily supportive care, rather than curing the disease. Rest, adequate hydration during fever, and some sort of pain reliever, as long as dengue fever is ruled out first, (in regions where it is active) so as not to cause hemorrhage.
Future treatments or immune mediating prevention would include vaccines similar to vaccines of other viruses, and antiviral treatment similar to those used for similar viruses. And as I mentioned in the EVD, it is likely that every known antiviral, antibiotic, as well as other drugs will be tried in a random fashion to see if anything works for the patients.
So what’s the problem?
Given everything I said above, it sounds like a relatively minor problem, not worse and perhaps easier to work with than influenza, where as I mentioned, there are 30,000 deaths a year in the USA alone. The issues lie around the following four points, which is where the main concerns lie.
Zika virus infection has been associated with microcephaly developing in babies carried by pregnant women. In other words, there has been a notable increase in the incidence of microcephaly in Brazil. Zika virus has been found in some of the mothers and it has crossed the placenta as well. While there has been this strong association, there has not been proof of causation to date. This may or may not stand. I know it sounds crazy, but believe me that while Zika virus may very well be the cause, it still has to be clearly demonstrated. But we can all see the problem. If it is spreading at tremendous rates, and it is found to be the cause of the microcephaly, this would turn into a huge disaster, in quick fashion. (I will describe this issue in greater detail in my next update, why we both don’t have proof of causality, yet have a good hunch about this link.)
While Zika virus has migrated, in at least one instance the infection was associated with Guillain-Barre syndrome, which is a polio-like paralysis occurring post infection or post exposure to neurotoxins.
Zika virus is considered an emerging virus that we are only still learning about. How bad might it get? How bad is it in reality? What are the potential neurological chronic sequelae?
Sadly, and lastly, we care more when we are likely to become infected. Once it became clear that EVD has not transformed to be airborne and was not likely to infect Americans, many just moved on with their lives. Once we knew that we would not be suffering from widespread cholera, we stopped caring that thousands die from cholera in Haiti. This one is a different story. This one is coming to America and will not stop at the border. From outdoor enthusiasts to mothers in the city parks with the children, we are all at risk for mosquito bites.
Because of these reasons, a great deal of energy will go into this inquiry. First and foremost, is there more microcephaly now, and if there is, is Zika virus the cause of it? Until we know that, out of abundant caution, you want to keep any woman who is going to get pregnant away from mosquitoes. This includes reconsidering travel to infected areas, but if there, doing all that is possible to prevent mosquito bites, and make sure her sexual partner is not bitten either, as the virus can be shared through bodily fluids. These precautions should be taken at the very least until we know if Zika virus is the cause of the microcephaly.
Half of the USA
Here I have to disagree with published comments from CDC that we are unlikely to have an epidemic of Zika virus infection in the USA. Basically it goes along the fact that the mosquito in question is not comfortable in the USA as we are too far north for it. And second, we know how to control mosquitoes better, and know how to protect ourselves from mosquito bites. I disagree with all three of these assertions. First, there is no way, at all, even in the slightest, that this is not going to hit the south of the USA. In a few weeks this will be obvious, and the CDC will shift their recommendations to include specific preparations for this spring and summer. And second, think about how often you get bitten by a mosquito. And third, we are in the midst of an el Nino year, with weather patterns in the south being warmer and wetter. Because of these reasons, the mosquito in question is going to inhabit the south like Florida and Texas more robustly, maybe even the wetter California. That just seems like basic sense. What is conjecture though is the following. The Zika virus may switch to be carried by to a related mosquito, and if so, the habitat of that mosquito covers nearly half the geographic area of the USA. See the problem? Nature has a way of doing this easily enough. In fact, if you track the known travels of Zika virus from Africa to the western hemisphere, you will see that it has done so, over and over. Will it do so this time? No way of knowing, but to say that Zika virus will not have local transmission seems an odd thing to say and will be changed shortly. (I will describe the mosquito issues in greater detail in my next update.)
For the clinician:
Understanding the history and the current situation, here is a reasonable way to look at this situation as it stands now.
1.If you live in the Southern parts of the USA, make the assumption that Zika virus will be there as soon as the mosquitoes are active.
2. Remember that most people infected will not exhibit symptoms.
3. Remember that the symptoms mimic influenza that is hitting the USA just now. If someone is sick with something that looks like influenza, see if they have Zika virus infection. Towards this end, keep track of the influenza data in your region, and once influenza is gone, and the mosquitoes arrive, then the influenza like illnesses should differentiate in your mind.
4. Help patients take precaution to prevent being bitten by mosquitoes.
5. Any woman in that area under your care that is of childbearing age and wants to get pregnant should probably be contacted by you to remind her that she can not be allowed to be bitten by a mosquito, and these are, at this time, the daytime mosquitoes, for now. DEET or Picaridin or oil of lemon eucalyptus, making sure that the percent is high enough to match the exposure time should be used. What I mean here is that the product you use may have the correct repellent but at the wrong percent. Higher percents are needed for longer exposure times. As well, remember protective clothing. Here, prevention is the key, and to a great extent prevention is possible with care and attention. Please try to avoid panic or causing your patients to panic.
The role of those practicing in naturopathic, homeopathic, CAM, and integrative medicine settings in general and during this time
Those in our fields have often acted in error. Most of the time it is due to good people having a poor understanding of what is naturopathically, CAM and homeopathically appropriate in a given situation. I hope for a better, more informed showing this time.
The highest level any physician can attain is that of offering primary prevention to those in his or her care. In this instance, primary prevention means limiting the number of people who are exposed to the virus, at least until we find out how severe it actually is, which means limiting bug bites. Spend your time there. You are most efficient and effective there. There is nothing ‘low level’ here or not ‘sexy’ here. It is the highest form of medicine.
As well, CAM practitioners can help provide care during this time if presented with an ill patient who was exposed to the virus. A natural or integrative medicine approach, such as a homeopathic remedy, matching the symptoms of the individual should be given. I base this on both basic humanitarian principles, as well as a form of precautionary principle. You are not preventing any other treatment that may be tried, and there, in that instance, there is nothing to lose. In all countries around the world, there are compassionate and early use clauses for application of early investigational therapies, for unapproved medicines under compassionate rules, even when the therapy has a potential of harm, but this is especially so if the medicine is safe, but not yet proven effective. For example in the USA, we have the following from the FDA, though there are more:
“Availability of Investigational Drugs for Compassionate Use,” and
“IDE Early/Expanded Access”
Under these circumstances, to prevent, ridicule, deride, or in other way diminish the likelihood of potential care to be given is in fact limiting access to healthcare—recognized by most civil society as a basic human right —and limiting access is contrary to the public good as well as decency. Put simply, while there may be no proof that homeopathy or other CAM approaches may help in this circumstance, there is also no proof that they will not help, and with homeopathy, we have 200 years of proof that it does not hurt. In any other situation, any reasonable, nonbiased scientist would try this. Here, you are offering treatment with the hope of preventing a problem for the fetus. At this time, in this situation the parent has to watch this unfolding of potential microcephaly. Using CAM approaches may or may not help, but not trying seems unusually cruel and inhumane.
Anything short of allowing access is an example of the ‘tomato effect’ seen in people acting unscientifically, and not in keeping step with the rest of science at the moment.
Most importantly, for the homeopath
Over the next days and weeks, you are likely to read on the web that this remedy or that remedy is the right one here, the genus epidemicus for this virus at this time. And you are likely to hear that all you have to do is either prepare an attenuation of the virus or secretion from an ill person with the virus, and that this will either cure or prevent this illness. That does not make sense. The correct treatment at this time is case by case. Unless something changes dramatically, there is not going to be a genus epidemicus in this instance. I laid out the logic around this 16 years ago and it still holds. I hope to encapsulate that in the next update on this topic, but for now, know that the very best thing you can possibly do it make sure their constitutional remedy is working. In other words, take an appointment with them, follow the normal rules of follow-up, repeat or change remedies or wait as according the patient’s situation, but in all instances, the idea of doing something different here does not make sense.
As I finish this update, weeks after I started, I realized that we have more than 30 people diagnosed with Zika virus infection in the USA. Again, this is very likely to explode in numbers. The numbers of Zika virus infection diagnosed people are likely to very greatly overshadow those of EVD, but the main question is not that, but rather how severe the virus is. More on that next time. Sign up to either our blog or Twitter for updates.
Until then, DON’T PANIC!
In health,
Paul Herscu, ND, MPH