ANNAPOLIS, MD. – The definition of taking a thorough travel history has expanded with the spread of Zika.
Physicians “need to focus not only on patients’ travel histories, but also the travel histories and future travel plans of our patients’ sexual partners,” Ilona T. Goldfarb, a perinatologist at Massachusetts General Hospital, Boston, said in an interview. “We cannot rely on our patients to just [offer] that they’ve been in the Caribbean. We have to ask them diligently, and at every visit.”
Dr. Ilona T. Goldfarb
Dr. Goldfarb added that immigration is a risk for Zika exposure, and may be a barrier to accurate history taking. In these cases, travel history will need to be performed in the patient’s spoken language to ensure accuracy, Dr. Goldfarb said. To track and communicate Zika information, Dr. Goldfarb and her colleagues have developed a three-part response based on their experience with previous infectious disease emergencies:
1. Communication. The practice is in regular communication with the Centers for Disease Control and Prevention and the state public health department to ensure they are up to date on all guidelines.
2. Education. Dr. Goldfarb and her practice colleagues routinely brief each other and patients on any new information, including recommended testing and guidelines, as well as travel warnings.
3. Tracking. Clinicians use a tracking worksheet for every patient screened for potential Zika exposure, allowing them to prospectively and retrospectively review patients. This has already proven useful, Dr. Goldfarb said, when the CDC changed its guidance around testing of asymptomatic patients.
In a presentation at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology, Dr. Goldfarb presented the data that she and her colleagues have collected so far on patients with Zika exposure.
As of Aug. 10, 2016, the practice had screened 142 women for Zika virus exposure since January 2016. More than 80% of the exposure came from travel to Zika-endemic areas. There have been few cases of exposure reported through sex, but Dr. Goldfarb said she thinks this type of exposure has been underreported because the link between infection and sex was not known until more recently.
Of the patients screened, 87% were appropriate candidates for Zika virus serum testing under CDC guidelines. There have been four positive serum tests for Zika exposure in Dr. Goldfarb’s patients so far.
In the one live birth, the newborn showed no visible signs of abnormalities. Testing revealed Zika virus RNA in the placenta, but not in the cord blood. The other three pregnancies were either terminated or associated with miscarriages. Again, Zika was detected in the placentas, but not in the fetuses.
Testing protocols have been a moving target since the outbreak began, according to Dr. Goldfarb. Some patients who call or are screened for possible exposure “are not actually eligible for testing because of the time frame or location of travel.”
To make sure that appropriate testing is being performed, Dr. Goldfarb advised designating an in-practice “Zika expert.” In her own practice, Dr. Goldfarb and one other colleague handle all Zika screening and inquiries from patients and colleagues. “This has greatly improved our efficiency and the experience for the patients,” she said in an interview.
The Massachusetts Department of Public Health is piloting a program with Dr. Goldfarb’s practice to determine if using the “designated expert” approach will improve laboratory wait times, compared with the standard protocol of having clinicians obtain approval from a state epidemiologist before sending patient serum samples for testing.
It has taken from 2 to 68 days to receive test results from the state lab, although a period of 17 days is typical, Dr. Goldfarb reported. The process has improved since last March when state health officials ramped up their capacity, she said.
As of Aug. 10, Dr. Goldfarb’s practice has performed 107 ultrasounds for patients with suspected Zika virus, averaging 3 per patient. Across all ultrasounds, there were three abnormalities, including one case of bilateral ventriculomegaly. Earlier in that pregnancy, the patient had tested negative for Zika on real-time reverse transcription polymerase chain reaction testing, which simultaneously screens for dengue, chikungunya, and Zika. Serum testing was also negative for Zika in the two other pregnancies with fetal abnormalities.
Dr. Goldfarb said she couldn’t quantify how much time is being spent on Zika screening and counseling since that is not being tracked, but she estimated that her practice takes between three and five calls or questions per day regarding the virus.
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