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 Doctors were on guard because federal health officials and the
World Health Organization (WHO) had warned 2015 would be a bad year
for dengue and possibly another viral disease, chikungunya, both
spread by the same type of mosquito.
But the symptoms of the hundreds of people seeking treatment did not
fit dengue. Instead of high fevers and intense muscular aches that
dengue is known to cause, patients were running only slight
temperatures and complaining of joint pain. Many had rashes sooner
than with dengue and chikungunya.
"We knew this was something else," says Carlos Brito, a doctor from
Recife who told state and federal health authorities in
January-February last year that they were wrong to classify all the
cases as dengue. "But the authorities were slow to believe,” he
said.
Kleber Luz, a physician in Natal, a city 300 km up the Atlantic
coast, says he gave similar feedback but got the same response. The
two - who were part of a group of doctors discussing the odd
symptoms in text messages - grew frustrated with the authorities’
narrow focus. They asked the federal health ministry to broaden its
search beyond viruses known in the area.
It took until early May for the health ministry to recognize that
the Zika virus had arrived in Brazil and to alert the WHO’s regional
arm, the Washington-based Pan American Health Organization. And it
wasn't until November that a Rio de Janeiro laboratory made a link
between the virus and microcephaly, which can lead to abnormally
small brains in developing babies.
The WHO has been lambasted in the past couple of years by
scientists, aid organizations, and public health experts for the
slow way in which it initially reacted to the Ebola epidemic as it
spread across West Africa in 2014. And so far, the hesitant response
to the Zika outbreak, which has created the worst global health
scare since Ebola, says much about the difficulties that the WHO and
other health authorities face in combating unexpected public health
threats.
EXPLODING ACROSS THE REGION
On Dec. 1, the WHO cited the lab evidence linking Zika to
microcephaly in an advisory to its member countries. It will
consider on Monday whether to declare an international emergency.
The WHO said in Geneva on Thursday that Zika in the last few months
has spread "explosively" to more than 20 other countries in the
Americas and could infect as many as 4 million people.
Whether the health authorities in Brazil and the leadership at the
WHO have taken too long to get to this point is a subject of debate
within the international health community.
The Brazilian government says its response when it was first alerted
by the doctors about the unusual symptoms they were seeing was
driven by the evidence.
“It was too early," said Claudio Maierovitch, director of the health
ministry's Department of Communicable Disease Surveillance. "There
are so many other viral possibilities and Zika had never been seen
in this hemisphere."
And he said that when Zika was identified, the authorities’ response
was based on knowledge of the disease. Previous outbreaks of Zika, a
virus first identified in 1947 in Uganda, had occurred in small and
scattered rural populations in Africa and Southeast Asia and the
symptoms were relatively benign.
"We based our response on the scientific knowledge available, that
Zika caused a mild illness without major complications," said
Maierovitch. "But as soon as we saw that there was an association
with microcephaly, we reacted in record time."
Critics say that the WHO has been slow to act after the link between
Zika and microcephaly was made, and should have declared an
emergency as soon as that was determined. "My chief criticism is of
WHO in Geneva. After being widely condemned for acting late on
Ebola, it is now sitting back with Zika," said Lawrence O. Gostin, a
professor of public health law at Georgetown University, who has
worked with the WHO and written extensively about pandemics and
policy.
WHO officials say the agency's response to Zika is driven by
science, and they point out that much remains unclear, including the
precise nature of any link between Zika and microcephaly.
"In any unfolding crisis you're dealing with a lot of uncertainty,"
Bruce Aylward, the WHO's assistant director-general, told reporters
on Thursday.
Since October, 4,180 cases of microcephaly have been reported in
Brazil but only 270 have so far been confirmed, with just six so far
linked by the government to Zika. Of the rest, 3,448 are still being
investigated through a long process involving clinical research,
laboratory testing and monitoring of the infants' development, and
462 were dismissed as not being microcephaly.
Following the spread of the disease is difficult. Many of those who
get Zika can recover quickly from only mild symptoms, and across the
Americas, hospitals do not have the clinical testing materials to
quickly and definitively determine whether a patient is infected.
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“I THINK IT’S ZIKA”
Luz, the Natal doctor, may have been the first person to make a link
between the symptoms his patients had shown and Zika.
After poring over scientific literature about a 2013 outbreak in
French Polynesia, Luz in early March sent a text to a WhatsApp group
for doctors, declaring: "I think it's Zika." He compared the
symptoms he had seen with those reported in that outbreak.
Soon, several doctors in the same region began collecting blood
samples from patients and sent them to various laboratories for
analysis. On April 30, a laboratory at the Federal University of
Bahia, also in Brazil's northeast, said it had identified the
presence of Zika in samples from one patient.
The health ministry alerted state governments.
On May 2, it notified PAHO. The notification put a Zika outbreak on
record at the WHO.
On May 7, PAHO issued an “epidemiological alert” saying “public
health authorities of Brazil are investigating a possible
transmission of the Zika virus.”
But concern remained limited mostly to the contagiousness of Zika,
rather than whether it could be a serious threat. In its alert, PAHO
wrote: "Complications (neurological, autoimmune) are rare."
'REAL ANGUISH'
In late May, Brito received a call from a Recife neurologist who
noticed a surge of new patients with symptoms of Guillain-Barré, a
little-understood autoimmune syndrome that can weaken the muscles
and cause paralysis.
Brito interviewed the patients, many of whom said they had
previously suffered a light fever, joint pain and rashes. He
collected blood samples and by June a laboratory had used genetic
testing to find traces of the Zika virus.
"It was real anguish," Brito said of the patient's suffering and the
wait for official confirmation of Zika's presence.
But despite the results, there was no proof to show that it was Zika
causing the syndrome. Neither the Brazilian health ministry nor PAHO
heightened warnings.
By September, the chat groups among doctors were abuzz over a spike
in the number of babies born with microcephaly.
Many mothers of affected babies recalled having Zika-type symptoms.
In October, Adriana Melo, an obstetrician in the nearby state of
Paraiba, noticed troubling signs in sonograms of a 34-year-old
expectant mother.
There were calcium deposits in the developing baby's brain, a
possible sign of viral infection. The cerebellum, the part of the
brain crucial for motor control, was shrinking.
Melo phoned the Oswaldo Cruz Foundation, a public health institute
in Rio de Janeiro, and got a lab there to test the patient's
amniotic fluid.
By then, the number of babies born with microcephaly was surging.
The health ministry, now more alarmed, declared a national emergency
on Nov. 11 and in public comments mentioned that there were possible
ties between the condition and Zika.
The WHO was not yet ready to draw the same parallels.
On November 17, the Rio lab said it had found the virus in the
amniotic fluid. On Nov. 28, after lab tests from another baby,
Brazil's government confirmed the link between the virus and
microcephaly.
Starting Nov. 30, WHO deployed a small team of researchers from
PAHO's Washington headquarters to Brazil.
On December 1, PAHO issued a new advisory, warning countries in the
region of the link between the virus and microcephaly. Two months
later, the WHO is considering whether to declare an international
emergency.
"You have to gather the data," says Marcos Espinal, director of the
department of communicable diseases at PAHO, dismissing criticism
that the regional body or headquarters could have moved any sooner.
(Additional reporting by Anthony Boadle, Brad Brooks, Stephanie
Nebehay, Tom Miles and Julie Steenhuysen; Editing by Kieran Murray,
Lisa Girion and Martin Howell)
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