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Zika rash and increased risk of congenital brain abnormalities – Authors' reply
2017; Elsevier BV; Volume: 389; Issue: 10065 Linguagem: Inglês
10.1016/s0140-6736(17)30015-6
ISSN1474-547X
AutoresCésar G. Victora, Márcia C. Castro, Giovanny Vinícius Araújo de França, Lavínia Schüler‐Faccini, Fernando C. Barros,
Tópico(s)COVID-19 Clinical Research Studies
ResumoPatrick Gérardin and colleagues state that “the data linking third-trimester rashes to neuroimaging findings are not shown”. In the Results section1França GVA Schuler-Faccini L Oliveira WK et al.Congenital Zika virus syndrome in Brazil: a case series of the first 1501 livebirths with complete investigation.Lancet. 2016; 388: 891-897Summary Full Text Full Text PDF PubMed Scopus (411) Google Scholar we mention that for nine cases, the mothers reported a rash in the third trimester. We have reviewed the records for these newborn babies: five presented with typical Zika virus brain malformations (eg, calcifications, ventriculomegaly), and physicians for the remaining four reported malformations without specifying their precise nature. Three other Brazilian studies suggest that late pregnancy infections can lead to brain lesions: in a prospective cohort,2Brasil P Pereira Jr, JP Raja Gabaglia C et al.Zika virus infection in pregnant women in Rio de Janeiro.N Engl J Med. 2016; 375: 2321-2334Crossref PubMed Scopus (1292) Google Scholar five of the 12 affected fetuses were born to mothers with a rash on gestational week 25 or later; a case report3Oliveira DBL Almeida FJ Durigon EL et al.Prolonged shedding of Zika virus associated with congenital infection.N Engl J Med. 2016; 375: 1202-1204Crossref PubMed Scopus (62) Google Scholar shows that a child infected at 26 weeks' gestation was still shredding the virus at 2 months of age; and a case-control study4de Araujo TV Rodrigues LC de Alencar Ximenes RA et al.Association between Zika virus infection and microcephaly in Brazil, January to May, 2016: preliminary report of a case-control study.Lancet Infect Dis. 2016; 16: 1356-1363Summary Full Text Full Text PDF PubMed Scopus (286) Google Scholar reports that three of 32 confirmed cases had a history of rash in the third trimester. To support their argument, Gérardin and colleagues cite a case series5Besnard M Eyrolle-Guignot D Guillemette-Artur P et al.Congenital cerebral malformations and dysfunction in fetuses and newborns following the 2013 to 2014 Zika virus epidemic in French Polynesia.Euro Surveill. 2016; 21: 30181Crossref Scopus (149) Google Scholar of 19 fetuses or newborn babies in Réunion, of whom five mothers reported a rash in the first trimester but none in the second or third trimesters. This small study does not exclude the possibility that neuroimaging findings might be found in the offspring of women with third-trimester rashes. In our view, the four Brazilian studies strongly suggest that Zika virus infections in late pregnancy can lead to brain abnormalities. Gérardin and colleagues' calculation of positive predictive value contains an error. Our receiver operating characteristic curve refers to definite and probable cases (including some that did not present rash), whereas the average head circumference they refer to is for third trimester rashes. They then state that a 67% infection rate is unlikely in Brazil, but 97% of our cases are from a smaller region—the northeast. A case-control study4de Araujo TV Rodrigues LC de Alencar Ximenes RA et al.Association between Zika virus infection and microcephaly in Brazil, January to May, 2016: preliminary report of a case-control study.Lancet Infect Dis. 2016; 16: 1356-1363Summary Full Text Full Text PDF PubMed Scopus (286) Google Scholar has shown 64% antibody prevalence among controls in Pernambuco state, where the epidemic was most intense. In addition, this state saw relatively few cases of infection in the summer of 2016 compared with the large number reported in 2015, suggesting that herd immunity might have been achieved—which is compatible with an incidence of around 60–70% in the first epidemic wave. In addition, note that our data show a marked regional distribution of the epidemic when it started, and therefore our results need to be interpreted considering this spatial distribution rather than extrapolated to the whole of Brazil. We declare no competing interests. Congenital Zika virus syndrome in Brazil: a case series of the first 1501 livebirths with complete investigationZika virus congenital syndrome is a new teratogenic disease. Because many definite or probable cases present normal head circumference values and their mothers do not report having a rash, screening criteria must be revised in order to detect all affected newborn babies. Full-Text PDF Open AccessZika rash and increased risk of congenital brain abnormalitiesIn a nationwide investigation of 1501 liveborn infants suspected of congenital Zika virus syndrome in Brazil, Giovanny V A França and colleagues (Aug 27, p 891)1 suggest that microcephaly and rash during pregnancy are sensitive enough to screen for cerebral malformations. In their study, the authors report that the earlier the rash occurred during pregnancy, the smaller the head circumference was at birth. Moreover, “rashes in the third trimester of pregnancy were associated with brain abnormalities despite normal sized heads.” On the basis of the average value of head circumference for third-trimester rashes (Z score −1·5 [SD 0·5]) and post-hoc estimation of sensitivity, specificity, and positive predictive values obtained from the receiver operating characteristic curve, we wish to express our concern that the data linking third-trimester rashes to neuroimaging findings are not shown. 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