Twenty-seven year old Farhana* is eight months pregnant. The resident of the Bhatta Basti slum in Jaipur’s Shastri Nagar contracted a fever in the second week of October. She went to a government hospital nearby, where her blood was tested. “Doctors told me that there was a blood infection, but it is gone now,” she said.

What she does not know is that subsequent tests of her blood samples, conducted by the Sawai Mansingh Medical College, showed the presence of the Zika virus. Transmitted through the bite of the Aedes mosquito, the virus causes mild symptoms of fever and rash for a few days, and in some cases, muscle weakness and paralysis. But when the virus infects a pregnant woman, it can alter the normal development of the foetus. The child may be born with microcephaly, condition marked by abnormally small heads.

There is a small chance that Farhana’s Zika infection can lead to developmental defects in her unborn child. But doctors at the Haribux Kanwatia Government Hospital, where Farhana’s blood samples were collected, said they had not been able to inform her about the risks after the results came in. “We tried to contact her over the phone, but the number was not valid,” said Dr Laqa Sultan, a gynaecologist at the hospital.

Since September 23, 140 people have tested positive for Zika in the capital of Rajasthan. Fifty of them are pregnant women like Farhana. It is unclear how many of them know about their infection and the associated risks.

The World Health Organisation recommends ultrasound scans at around 18-20 weeks of pregnancy for Zika positive pregnant women to detect microcephaly in the foetus. It also recommends screening the babies born to them for microcephaly and other birth defects, and tracking their health for two years to identify developmental delays and other neurological abnormalities.

While India’s Union health ministry released national guidelines in February 2016, on surveillance, response and risk communication in case of a Zika outbreak, the document is silent on how pregnant women should be monitored and counselled.

“We do not have protocols on the care for pregnant women,” said Veenu Gupta, additional health secretary with Rajasthan’s Ministry of Health and Family Welfare in a press conference on October 22. An official in the Union Health Ministry said the guidelines are in the process of being drafted.

In the absence of India-specific guidelines, how is Rajasthan monitoring the cases of Zika-positive pregnant women?

Detecting microcephaly

Shastri Nagar in Jaipur is the epicentre of the Zika outbreak. Most of the 140 Zika-positive cases, including the 50 pregnant women, live here in small homes in overcrowded slums.

At the Haribux Kanwatia Government Hospital, the main health facility in the area, doctors say they are reading up scientific literature to understand the best way to respond to Zika-positive pregnant women.

“I have told my gynaecology department to ensure they order monthly ultrasound scans for Zika positive pregnant women,” said Dr L Harshvardhan, the hospital’s medical superintendent. “I have also asked the radiologist to inform whenever he comes across a microcephaly case.”

Dr Oby Nagar of the Federation of Obstetric and Gynecological Societies of India and a professor at Sawai Man Singh Medical College said that all women who come for regular antenatal check-ups are supposed to get ultrasound scans at between 18 weeks and 20 weeks of pregnancy to detect anomalies, including microcephaly. “If we detect microcephaly or abnormality in the foetus before 20 weeks, the patient can choose to undergo abortion,” said Nagar.

The catch here is that microcephaly is difficult to detect in a foetus. There may be indication of the condition in a scan taken up to 24 weeks but definite signs can be seen only after 32 weeks, said Nivedita Gupta, a senior scientist with the Indian Council for Medical Research. Under India’s Medical Termination of Pregnancy Act, a doctor is permitted to provide an abortion only up to 20 weeks of pregnancy. After this deadline, a woman who wants an abortion must approach the courts for permission to have one. In such circumstances, some doctors say repeated ultrasound tests may serve little purpose but only cause stress to a woman in advanced pregnancy.

Farhana, who has two children, is at the end of her third pregnancy. She has had three to four ultrasound scans in the past eight months. “Doctors said that my child is weak,” she said. Beyond that, she said she has not been informed of any other risks.

The risk of birth defects is highest if the infection occurs in the first trimester of pregnancy and lowest in the last trimester of pregnancy. According to the United States’ Centres for Disease Control, studies in the US and in US territories show that there is a 8%-15% risk of a baby being born with birth defects in case of a first trimester Zika infection, 5% for the second trimester and 4% for the third trimester.

Said Gupta, the additional health secretary of Rajasthan: “We are focusing on the Zika positive pregnant women in their first trimester of pregnancy. The risk is barely anything for the women in the later stages of pregnancy.”

The Brazilian strain

On September 23, Rajasthan health authorities confirmed the first case of Zika in Shastri Nagar, when the blood samples of an 85-year-old woman showed the presence of the virus. The samples were tested randomly at the Sawai Man Singh Medical College during a regular Zika surveillance programme. They were confirmed as Zika positive by National Institute of Virology in Pune.

The institute sequenced the entire genome of the Zika virus obtained from this sample, in the same manner that it examined samples from Ahmedabad, Gujarat, where three people had tested positive for Zika in January 2017. While the Gujarat Zika strain was found to be closer to the 1966 Malaysian strain, the Zika strain from Rajasthan bears similarities to the virus that caused the recent outbreak in Brazil.

In 2015, Brazil reported an unusual increase in the number of cases of microcephaly among newborns after an outbreak of Zika. At the peak of the epidemic in 2015, the number of Zika cases were estimated at 49.9 cases per 10,000 live births as against the average risk of microcephaly in Brazil of two cases per 10,000 births. The WHO considers the normal range of microcephaly cases where Zika is endemic to be between 0.5 to 20 per 10,000 live births.

The Brazilian government declared a national public emergency and created a Public Health Event Registry to identify cases of microcephaly and other congenital anomalies. In 2017, a study published in the medical journal Lancet using this data concluded that most infection-related microcephaly cases were concentrated in the northeast region of Brazil. Another study published in March this year showed an association between microcephaly and congenital Zika virus infection. While these studies do not show a direct causal link, they show strong association between Zika infection in pregnant women and microcephaly.

Daniel Vieira, who is two years old, and was born with microcephaly, is greeted by his brother at their house in Olinda, Brazil, August 7, 2018. During her pregnancy, Daniel's mother Jackeline Vieira de Souza learned that her son had microcephaly. "When he was born, I fell in love with him because I knew he would be a good thing in my life, even with the difficulties I would have to face." Daniel's father separated from Jackeline shortly after learning that his son had microcephaly. He pays a small amount of family support every month, in addition to a monthly check that Jackeline gets from the government. It takes several hours to travel by bus between their home in Olinda and Recife, where Daniel goes for treatments. Lately, those trips are somewhat less frequent, and Jackeline believes Daniel's health is more stable. She has no illusions that her son will ever walk, eat on his own or live a normal life. Yet in many ways she is grateful for her "miracle" baby, who she says makes her feel "happy and more accomplished". (Photo: Ueslei Marcelino/Reuters)

But it is not clear yet if the Zika strain that carries the specific mutation that causes microcephaly is present in Jaipur. While testing the first sample, the National Institute of Virology “did not find the specific mutation that is known to cause microcephaly,” said Nivedita Gupta, a senior scientist at the Indian Council for Medical Research, which oversees the work of the institute. “But we are in the process of sequencing four to five strains of Zika virus found in Jaipur at different time points of the outbreak.”

The Indian Council for Medical Research also plans to monitor the pregnancies of the 50 women who have tested positive for Zika in Jaipur, and track the growth of their children to record any developmental abnormalities, said Gupta. “The research evidence will help policy makers to formulate evidence-based decisions for handling Zika positive pregnant women and subsequently newborns of such mothers.”

However, the council is yet to formulate the protocols for such a study.

Surveillance and awareness

Meanwhile, Rajasthan health authorities have stepped up Zika surveillance in 14 of Jaipur’s 91 wards that have been defined as the “containment zone” of the current outbreak. Anyone reporting symptoms like fever, conjunctivitis and rash, as well as all pregnant women are being tested for the virus.

Of the 50 pregnant women detected as positive, 60% were asymptomatic, which means they did not have any symptoms of a Zika infection, said Nivedita Gupta. But this does not rule out the possibility of complications in the foetus. “Even when there is a low viral load in the body and the patient is asymptomatic, there is a risk that the virus can pass through the placenta [to the foetus],” she said.

Health authorities have been handing out pamphlets to households in these 14 wards about precautions to be taken in the middle of an outbreak. The pamphlet contains information about how Zika can spread through mosquito bites, sexual contact and blood transfusion. It also warns that the virus can be be transmitted from mother to foetus and of the abnormalities the child can be born with.

All this has made 27-year-old Priya* nervous – she is expecting her first child. She lives with the 85-year-old woman who was the first Zika positive case in Jaipur. The entire family has been tested for Zika. All of them, including Priya, tested negative. But the last time she was pregnant, she had a spontaneous abortion. She is now worried about her current pregnancy.

“The doctors told me to go out of the city for some time,” she said. “I went to a relative’s house in Tonk.”

Priya returned to Shastri Nagar after 10 days. “I hope everything goes well,” she said.

*Name changed to protect privacy.

Update: After this report was published, a spokesperson of the Ministry of Health & Family Welfare emailed a statement to on November 2. The statement said the ministry had shared “the updated Zika testing protocol for pregnant women” with Rajasthan Government on October 13, 2018. “The draft protocol for managing pregnant mothers exposed to Zika virus was discussed with the State on 17.10.2018 wherein the main interventions were conveyed. The final document was shared with the state on 1st November 2018.”

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