Nancy E. Dirubbo, DNP, FNP, FAANP is a family nurse practitioner and a Fellow of the American Association of Nurse Practitioners. Nancy is currently seeing patients at her clinic in New Hampshire who have expressed concerns about the outbreak of the Zika virus. In 2008, she founded Travel Health of New Hampshire, which was a certified yellow fever vaccine center. In 1985, she started her own practice, the Laconia Women’s Health Center, which is one of the oldest nurse practitioner-owned and operated primary care practices in the United States. Nancy is certified in travel health by the International Society of Travel Medicine.
You are currently seeing patients in your New Hampshire clinic who have expressed concerns with the Zika virus. How serious of a problem is it here in the US and what do you tell patients who are worried about it?
Right now things are very fluid. This is a virus that is in the Caribbean, in Mexico, in Central America, that does affect travelers and is going to have an impact in the United States. What I try to explain to people is that, like other insect born diseases, we need to take precaution in areas that we know have the Aedes aegypti mosquito, which is capable of carrying this virus and dengue and chikungunya. We need to take insect precaution. The biggest concern right now is for women who are pregnant or who may be trying to conceive who may have been exposed to the Zika virus. There has been an observed connection between Zika and microcephaly, and just this week we had a case of microcephaly in Panama. So we are now seeing it outside of Brazil.
What I’m telling people now is that if they are pregnant, they should not travel to an area where Zika is known to be. If they are planning to get pregnant in the very near future– same recommendation. If it’s not emergency travel, don’t do it. I’ve had a few private schools in my area that I do pre-travel consultations for, and in more than one instance, people have changed their plans because they were actively trying to conceive and they were planning on going with students as chaperones on trips where Zika is reported, and they backed out, and I think that’s a very reasonable course of action. I’ve had elderly people who are worried because their daughter is pregnant and they are taking a cruise in the Caribbean and I try to explain to them that there is not known human to human transmission of Zika, other than sexual transmission.
How would someone know if they had the virus?
80% of patients show no symptoms at all. And if they do have the disease, it is very, very mild symptoms- a mild rash, eye irritation and a low grade fever. There is possibly an uptick in the number of cases of a condition called Guillain-Barré Syndrome (GBS). We want anyone who is going to places where Zika is found to be very careful about avoiding insect bites, and the biggest concern is for pregnant women, or those getting ready to conceive.
Let’s say I am going to get tested. Give me the play by play for the testing process from the doctor’s office to the lab until the results are in.
Right now the only place you can get a test for the virus is through the CDC. So you can’t go to your local provider’s office and say, “I want to be tested for Zika, can I get a test?” If a provider sees a patient who is symptomatic and is pregnant or has any neurological symptoms of GBS, blood tests can be drawn, and the blood gets sent to the state laboratory. The state laboratory then is the funnel for the specimen to go to the CDC, and they do a test for antibodies for the Zika virus. So right now, because we have limited resources for testing, only people who are significantly at risk and need to know if they have it are being tested.
Mostly pregnant women?
A pregnant woman who has had known exposure to Zika, or a pregnant woman with an abnormality in fetal head size by ultrasound would be tested. Blood would be drawn locally and sent to the CDC via their state department of public health division’s protocol. Those tests would then go through the state department of public health and then the CDC for testing, and it would take probably two to three weeks to get results back. They are working on an in office finger stick blood test with results available quickly, such as we have now for influenza.
Why aren’t we hearing about these other viruses?
My personal opinion is the media. About two years ago, there was no Chikungunya anywhere in the Caribbean or in Mexico. Now it’s virtually everywhere. Chikungunya makes you feel miserable. It’s like the flu on steroids. You have severe muscle aches, you may have a fever, there are flu like symptoms, but within two to three weeks, you’ll be over it. A small percentage of people go on to have significant joint pains afterwards for years, but it doesn’t cause the microcephaly, and I think that’s what has captured the media’s attention. Pictures of babies born with small heads that don’t look normal is compelling. If someone contracts chikungunya, they are very unlikely to get it again, as there is antibody protection, but we don’t know if that is the case with Zika virus. There are different subtypes of dengue, so if you get it once, you could get it again. The first time you may be quite miserable with fever, headache, and muscle and joint pain, but you will recover. If you contract dengue again, your chance of having a severe form hemorrhagic dengue increases and hemorrhagic dengue can be fatal. Travelers aren’t likely to get dengue more than once, so the risk of fatality from dengue is low. Certainly preventing an initial outbreak is prudent. People who live in areas where dengue is endemic do die from it. We really don’t know how many stillbirths or miscarriages are from Zika because those people in low resource countries that have miscarriages or stillbirths don’t report them or have tissue tested to try to determine the cause of the fetal demise. So while the risks of morbidity and mortality and the numbers of those affected worldwide are greater for dengue and chikungunya, the tragic consequences of neonatal complications of Zika even in small numbers has captured attention and created more concern.
Are we seeing dengue and chikungunya in the US as well?
Yes, we’ve actually had cases of dengue in Florida and Texas that were believed to be native transmissions, not just people returning back from trips. Two weeks ago I was in Nicaragua doing a medical mission trip and we actually did see cases of both dengue and chikungunya.
Have you treated any patients who have tested positive for these viruses in the US?
I have not, but I do know of colleagues who have, and I have treated patients who were previously diagnosed with these diseases. I think a lot of them go undiagnosed. I’ll give you an example. Three or four years ago I was in the Dominican Republic doing a medical mission trip and a few of the nurses that were on the trip were doing it on a yearly basis. We were sitting around one night after seeing some patients with dengue, and they said, “you know what, every time we go to the Dominican Republic, a couple of weeks after I get back, I get the flu, and I always get flu shots and the timing is always so strange.” So they described their symptoms, and it was the compelling muscle aches that they were talking about that made me think maybe this isn’t the flu. I brought that up to them and said, “you know, this may not be the flu at all.” They actually went back and they got a test. There is a test you can do to look for circulating antibodies from older infections, and they both tested positive for dengue. So they had it, thought it was the flu, and never got it diagnosed. I don’t know how often that happens, I would say probably a lot. Most people, when they come back from vacation, are traveling on planes, so they know they get exposure to flu. If they get sick with flu like symptoms when they come home, many don’t see a provider at all. If they do and they don’t tell their provider they were in dengue endemic areas, they aren’t likely to be tested. How many cases are being underdiagnosed?
Dengue and chikungunya can pass with time. How long will Zika stay in the system?
We don’t know. There are so many things about Zika that we don’t understand. We know the initial infection seems to be seven to fourteen days, but there is a lot about this virus that we just don’t understand and don’t have answers to.
How do you see the health industry dealing with the outbreak over the next few years?
I have concerns that it’s going to affect tourism and travel, especially to low resource areas that are really dependant on that financial stream. What’s interesting to look at is the fact that most of the industrial world pretty much doesn’t pay a whole lot of attention to diseases that are very common in low resource countries. That includes malaria and Zika. Zika has been around since the 1940’s, it’s not a new virus, it’s been around, but nobody paid a whole lot of attention to it. The world is becoming a smaller and smaller place. It’s so easy for a microbe to infect someone and travel on a plane and spread to places where it’s never had the opportunity to before. As a world, we need to be looking at all kinds of infections that can become endemic and pandemic and be prepared to deal with those. We could have had a vaccine for Zika years ago, but there was no interest in it because there was no money in it. When it affects low resource countries, and people are poor, things don’t get produced or taken seriously until they start to affect countries who have more money and more resources.
It’s interesting to look at this as a policy issue. I’m sure they’ll be able to develop a vaccine for Zika pretty quickly. They are working on vaccines for dengue. We are slow about getting vaccines processed in the United States because of our regulatory process. They are offering dengue vaccine now in Mexico and Brazil. I don’t know how long it will take for the U.S to approve such a vaccine. There are a lot more reactions to vaccines, almost bordering on phobias in the U.S. Some people have beliefs about vaccines that are disconcerting. When you study what these diseases are capable of doing and compare the scientific research about vaccines, there is a disconnect in some people as to the risks of vaccines versus the benefits that are not based on fact.
When H1N1 came around, for example, one of the things I did in my office was I got the shot first. Everyone in my family got the shot, my secretary got the shot, her family got the shot, and what I told the patients was, “I want to prove to you that this is safe and effective, and also, if I get sick or my family gets sick, I’m not going to be here to take care of you.” I think as providers, we can be role models and say, “this is safe. We’re jumping on the bandwagon too. I’m on the same boat as you are,” and perhaps I have a greater exposure because I’m taking care of sick people.
Flu kills about 35,000 people a year in the U.S and we have a vaccine to prevent that. That has the same number of deaths as something like breast cancer. Not too many more people die of breast cancer each year, but people are cavalier about getting a vaccine that is safe and proven to reduce morbidity and mortality. If we had a vaccine for breast cancer, I don’t think people would have the same reaction to it as they do to the flu vaccine. It doesn’t make sense when people don’t avail themselves of flu vaccine and treat it differently than all the other vaccines.
What else can we do as patients or healthcare providers to take action?
Make sure that the information you get about a health issue like Zika is from a reputable media source. The CDC is doing an excellent job of getting accurate, current information out there. Their website is very user friendly for consumers and the media as well as providers. I think if people only get their information from Facebook, for example, then they react with fear, rather than knowledge. I think it’s important to get accurate knowledge and stay abreast of it, because this is not going to go away.
I spend so much time in my travel clinic telling patients about proper insect repellent use. People often say, “DEET is very affective, but I’m afraid of DEET,” for no particular rational reason. DEET has been around since the 1940’s. It was developed by the government. It can be used on babies two months and older, and I think people sometimes confuse DEET with DDT, but these diseases are very serious. If you look at things like herbal remedies, or citronella, you can find studies online that will say that this is affective, but when you drill down into the data, maybe they repel insects, but only for ten to twenty minutes. Are you going to be reapplying this stuff constantly for it to be effective?
People on vacation want to be in relaxation mode. They want to mentally disconnect from everything, so they just want to lie on the beach in a bathing suit and not worry about sunscreen, not worry about bug spray, and not have to worry about anything. We need to be very careful about the places we expose ourselves and our families too, and to take precaution. I think a lot of it can be common sense. Cover up, put on insect repellant, and follow the directions for reapplication. If you are pregnant or trying to get pregnant, there will be some places you won’t want to take the risk and travel to.
Should everyone who is concerned get tested?
When we came back from Nicaragua a few weeks ago, some people said, “I think I’m just going to get tested for Zika because I want to know if I got it.” We need to be very careful about how we use our medical resources. One of the questions I always ask myself as a provider before I order something, is “is this going to shed more knowledge and change the way I’m going to treat this patient?” If it’s not going to add anything to my decision making and treatment plan, then I don’t need to do the test. When you only have a limited amount of resources and it only inflates the cost of treating and diagnosing the disease for people who just want to know, it’s just not a wise use of resources. As a good health consumer, I want to be sure that that’s one of the things I am being conscientious of and being an ethical user of the healthcare that we are so fortunate to have in the United States, but certainly that is not the case for someone who is at risk, like someone who is pregnant.
Would you say the same to a patient who came to you with concerns but no symptoms?
I would take that as a moment of opportunity to educate someone, and perhaps try to drill it down to what their actual fears are. Is it a lack of education? Are they worried about something else that they’re not really articulating? I would take a minute and not just say, “no, that’s silly, you shouldn’t be tested, but what are you really concerned about? How is this going to impact you?” Sometimes we think we are totally in charge of what happens to us and in nature and in health care and that we’ve got it all figured out; there are going to be other diseases, particularly as people come in contact with other people all over the world and then travel so quickly. It’s one of the side affects of travel and technology. It’s amazing when you think this itty bitty mosquito that you don’t even feel bite you can raise such havoc with the human race. Mosquitoes have killed people more than, I think, almost any other cause of death.
If you think about American history- Boston, Philadelphia, Washington, and New York all had malaria at the time of the revolution. There was a debate about Washington being the capital because of malaria. They drained the swamps and treated the areas and got rid of the mosquitoes that needed huge swampy areas to propagate, so we don’t have malaria in these areas anymore. The problem with the Aedes aegypti mosquito is that they need small amounts of water to breed. So in a tropical area where it rains daily, there are small areas for mosquitoes to breed everywhere. As human beings, we need to look at our relationship to nature and figure out how we’re going to cope with all these insect born diseases that are causing diseases such as Lyme, West Nile, and Zika. Insects are very efficient transporters of disease and combined with modern travel, makes us only as safe as the most vulnerable places on earth.