Aëdes to Zika, an Infectious Journey
As May became June in 2017, headlines hollered Zika Virus in Bapunagar! Named for the Mahatma, this locality of Ahmedabad, Gujarat, was known only for religious riots and the detergent Nirma.
Zika Virus is carried by the common mosquito Aëdes aegypti. What’s so new about that?
We have lived with this mosquito for millennia. And India has had this virus at least since 1953, when Zika was counted among the commonly circulating viruses in a serological survey of the population.
Yet in all these years it has never caused disease in India.
Ahmedabad does not have a Zika Fever outbreak. The virus was isolated from the blood of three people.
It is, still, more than enough cause for dread.
What is the difference between Zika in 1953 and Zika now, in 2017?
As this book goes to press, the blame game is being played out.
Let us cut through the white noise and examine the facts:
• In November 2016, a thirty-four-year-old woman delivered a normal infant after a normal pregnancy. She developed a low-grade fever soon after and was screened for dengue. Her blood sample tested positive for Zika Virus. She recovered within the week.
• In January 2017, as part of antenatal screening, 111 pregnant women were sampled. One tested positive for Zika. No further information has been released about the outcome of her pregnancy which, really, is the only vital question here.
• Between 10 and 16 February, Ahmedabad’s B.J. Medical College conducted a surveillance of acute febrile illnesses. Ninety-three people were tested, and among these, a sixty-four-year-old man was positive for Zika Virus.
These facts were communicated to the World Health Organization (WHO) in May 2017, a shocking and irresponsible delay. When the WHO’s website put an end to secrecy, our government admitted to the facts.
Public outrage and confusing press reports obscure the true implication of these facts.
The three people who tested positive have very likely resumed the even tenor of their days.
The ICMR * examined 34,233 human and 12,647 mosquito samples for the presence of Zika Virus. Five hundred mosquitoes were captured in Bapunagar and tested. They were all negative.
Governmental agencies are monitoring all births at fifty-five locations and they have, so far, reported nothing unusual.
Zika Virus is sexually transmitted. It can affect the developing brain of the unborn baby. It can produce a life-threatening paralysis. It may have any, all, or none, of these effects. It may be totally benign, a mild fever that passes without a trace.
It has run an unpredictable course everywhere on the planet. Can we predict how it will behave here, on our street?
India has 24 million pregnancies each year. Are these safe from Zika infection?
Will we face a generation of brain-damaged infants?
What do we have to offer 48 million miserable young couples other than a new bleat of stern diktats?
As we write this in July 2017, by next week, if not already, every quack, every vaidya, every hakim will tout a Zika remedy. Anti-Zika mantras will be exhumed from ancient texts. Yogic contortions will be taught in schools and colleges as time-honoured Zika remedies. Never mind that the word Zika was unknown till last week.
What is this virus?
Where did it come from?
When did it get here?
Why is it suddenly so dangerous?
How does it affect the body?
How does it spread?
Why should a mosquito which is already, very efficiently, spreading Dengue and Chikungunya decide to acquire and transmit Zika?
We need answers.
With every good intention, wise directives carry all the bravado of a child who whistles past a graveyard hoping to scare away ghosts. And are about as effective.
Are we so credulous a people?
The only apotropaic is the rational understanding of any situation.
To arrive there we must embark on the tortuous, infectious, and thrilling journey from Aëdes to Zika.
I was catapulted into that journey a year ago.
29 January 2016
Friday evening. January was drawing to a close. Dusk was in its last flare of brilliance as I introduced my recent book on plague to a small and very reactive audience.
I mentioned a curious coincidence on the day the book was released. The New York Times ran an intriguing story. It was about an attempt to ‘type’ the Big Apple’s genomic profile by examining swabs from public places.
If it seems strange that a city can claim a genome, think again.
What better method to understand the various forms of life it contains?
These researchers were looking for DNA evidence of common microbes in places with dense human contact. And one microbe they found aplenty was Yersinia pestis, the plague germ.
Did New York have the plague?
Far from it.
The study elucidated a different truth.
This truth is central to our present understanding of disease. Although self-evident, it never fails to shock when stated flatly.
‘No matter where we live on the planet, bacteria and viruses are part of the landscape,’ I explained. ‘We co-exist peacefully until something tips the balance and makes us enemies.’
A voice rang out: ‘Then why, suddenly, do we have Zika?’
Many things happened at that moment, as if the room had been seized by a poltergeist. The overhead fan whipped up a hurricane velocity. Spectral flashes of static crackled as electric tennis racquets were conjured up and slapped around wildly.
People rushed in all directions to shut doors and windows. Somebody switched on the lights.
The motive force for this tumult was already amongst us.
A baby had entered the room.
He gurgled approvingly at all this excitement. I noticed a necklace of red wheals visible beneath his curls. It quite justified the frenzy.
‘Did I hear you say Zika?’ his mother wailed. ‘I’m going there next week!’
‘Where’s there?’ I asked, unwilling to believe she was off to trek the Zika Forest.
It turned out she was going neither to Uganda nor to Latin America. California was her destination, and, they don’t have mosquitoes, do they?
I was forced to disillusion her. California has an abundance of diptera.
The baby’s mother asked, ‘It won’t affect baby, will it?’
The room stilled as if the very air depended on my answer.
What could I possibly say?
Zika Virus might have zipped across the planet unnoticed if not for a cluster of babies born in Brazil with microcephaly. Had their mothers been infected with Zika Virus? The jury was still out on that.
The baby began to cry, upset by the morose company.
I assured his mother he was safe.
I did tell her the health warning could not be ignored: pregnant mothers with Zika Virus could transmit the infection to the foetus. It wasn’t yet certain that those babies in the news had developed small heads because of Zika Virus.
My words sounded as lame as the reports I had been reading, but they seemed to make sense to the audience.
To me, by then, everything was white noise.
The discussion went on, but I had tuned out. My brain was being compelled into hearing a very different music. A hum, a buzz, a bombinating monotone, tedious, and faintly menacing. It was the song of the mosquito. I had the tune, but the lyrics were missing …
‘Could Zika Virus turn up here? In Bombay? In India?’
The question cut through the buzz in my skull.
The audience was quick with answers.
‘Not if we keep a strict watch at airports.’
‘What are they going to watch exactly?’
‘They’ll quarantine passengers from Brazil.’
‘Oh don’t be extreme! Brazil’s on the other side of the planet—’
‘Walls can’t be tall or strong enough, if you ask me!’
‘They should be the ones to act. People shouldn’t be allowed to leave Brazil till it’s safe.’
‘What’s safe? How long does it take to be safe?’
‘Immune, you mean?’
‘Can you be immune and still spread the virus?’
‘It spreads through sex.’
For the next few minutes, the silence of the grave was loud by comparison.
Sexually transmitted infections are edgy. Opinions retreat politely and cozy up on global warming.
‘I thought you said mosquito bite,’ someone persisted.
‘Can’t be both. You don’t transmit malaria or dengue or chikungunya through sex. I haven’t heard of that.’
‘Body fluids,’ a voice bubbled richly before a loud sneeze shook the air.
The questions kept coming, and we had no answers yet.
The Zika Virus is a paradox. The illness it causes is so trivial it can be dusted off as a day’s malaise. We may never have noticed it at all without its nightmare corollary, the most horrendous of all nature’s mishaps—a malformed baby.
A year after that conversation, am I any the wiser?
Oh, there is plenty of information, but how does it all add up?
Everything hinges on two babies.
The story of the European baby is pretty well known by now.
It is, really, the mother’s story.
It is the archetypal story of Zika Virus infection, valued for its completeness and attention to clinical detail.
To this young mother we owe our most complete understanding of the disease. She showed great strength and resolve in looking beyond her own suffering, and willingly offered its painful details to public scrutiny. Convention demands that she remain nameless, but I’ll call her Nadya, which means Hope.
In February 2015, Nadya, then twenty-five, discovered she was pregnant. Nadya was a volunteer in Natal, the capital of Rio Grande do Norte, a state in northeastern Brazil.
In the thirteenth week of pregnancy, she fell ill. She developed high fever and pain in her joints and behind the eyes. Soon she noticed a rash as well—a flat reddish coalescing itchy eruption.
Nadya wasn’t surprised. Many of her neighbours had similar symptoms of fever and rash. Natal was in the grip of Zika Virus Fever.
Nadya received good antenatal care. A sonography in the twentieth week showed a normally progressing pregnancy.
In her seventh month of pregnancy, Nadya returned home to Ljubljana, Slovenia.
In Ljubljana, Nadya registered for antenatal care, and as part of the initial workup, underwent sonography again.
This sonogram was worrying. What was happening within the baby’s head?
A constellation of calcific spots stippled the brain. In addition, the ventricles—the brain’s cavities through which nourishing cerebrospinal fluid circulates—were dilated.
This could mean brain damage.
The wait was agonizing, but there was no way to know for certain just then how bad it could be. The baby grew sluggish, it didn’t kick as often as before.
Three weeks later, when the sonogram was repeated, Nadya learned the worst.
Her baby had an abnormally small head and a severely damaged brain.
Nadya’s own body told her she was carrying a baby that was no longer very active. It had poor chances of survival. Its physical condition was tenuous given the evidence of growth retardation. If it did survive, its mental and intellectual abilities would be severely impaired.
Nadya made the decision to terminate her pregnancy.
The pregnancy was terminated at thirty-two weeks.
Nadya volunteered all the information needed to build a genetic profile. There was no record of disease or birth defects or heritable illnesses in her family.
She also permitted an autopsy on the foetus.
The story of the other baby has not yet been told.
Her mother, Asha, lived in my neighbourhood. In the most crowded part of India’s busiest city. Like Nadya, Asha too was twenty-five. This was her third pregnancy.
Asha worked an eight-hour job as a maid throughout her pregnancy. Antenatal care? She had seen the doctor to confirm her pregnancy and book a bed for delivery. She hadn’t given it another thought until the baby stopped kicking.
That was worrying. She endured the day at work somehow, telling herself all she needed was an hour of quiet and the baby would feel right again.
The day dragged on, the children were fractious, her bickering sister-in-law was spoiling for a fight, the tap ran dry a full hour ahead of stipulated time.
Her husband Manoj came home later than usual. After putting the children to bed, Asha ate her dinner on the fly as she washed and cleaned. It was only when she got to bed that she faced her anxiety.
The baby hadn’t moved, not once, all day.
Manoj was already asleep, it would be cruel to wake him with her worries.
In the morning, she told him they would have to see the doctor.
‘It’s early yet, isn’t it?’ he asked.
‘Three weeks early. But it hasn’t kicked since yesterday.’
Manoj felt her belly anxiously. She laughed at the fear in his eyes. ‘Don’t worry, everything’s just fine.’
But it wasn’t.
That afternoon, Asha delivered a dead baby.
The obstetrician called a paediatrician when she noticed the baby’s abnormal head.
‘Microcephaly,’ the paediatrician shrugged. ‘Happens sometimes.’
Nobody asked for an autopsy.
‘What killed the baby?’ Manoj asked. ‘Was it because Asha worked through her pregnancy? She wasn’t sick.’
‘What did I do wrong?’ Asha asked.
The doctor said, ‘It just happens sometimes. Too late now to do anything about it. But next time… There should be no next time. Two children are enough for you.’
Zika Virus maybe unknown in India, but microcephaly isn’t.
Asha and Nadya share the same anguish.
This is how I read it, and this is how I will write it.
During its years of oppression, the city of Ljubljana was encircled with barbed wire, first by Fascist Italy, later by Nazi Germany. This is preserved in the Trail of Remembrance and Comradeship, a paved walkway so lavishly verdant it is called the Green Ring. Through all its idyllic beauty, its perimeter still defines that old construct of pain.
To Nadya and Asha, and to the unnamed thousands of young women everywhere who walk the barbed wire, this book is dedicated with hope.
1 The Indian Council of Medical Research (ICMR) based in New Delhi, was set up in 1911 and functions under the aegis of the Union Ministry of Health and Family Welfare.