SUMMARY: Preventing mother-to-child HIV transmission is considered one of the most basic goals for curtailing the AIDS epidemic, and Nigeria is struggling mightily. In our series The End of AIDS, William Brangham and Jason Kane examine why this oil-rich nation is falling so badly behind, and profiles a unique, church-based program that’s showing real promise.
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SUMMARY: In the wake of the CDC's revelation that Zika virus causes microcephaly in infants, doctors are grappling with the thorny issue of whether they should recommend that women in high-risk areas avoid getting pregnant this summer. Hari Sreenivasan talks to Dr. Peter Hotez of Baylor College for more on how medical experts are confronting the prospect of Zika in the U.S.
HARI SREENIVASAN (NewsHour): Worries over a potential Zika outbreak in the U.S., and who may suffer a bigger impact.
Public health officials have been increasingly concerned about the virus spreading via mosquitoes this summer. One report even suggested government officials were split over whether to advise women to avoid pregnancy in areas where Zika is circulating.
In an op-ed titled “Zika Is Coming,” Dr. Peter Hotez focused on some of these questions and what it might mean in some cities in the southern parts of the country. He’s the dean of the National School of Tropical Medicine at Baylor College of Medicine and a pediatrician and microbiologist at Texas Children’s Hospital. I interviewed him from our New York studios.
I want to read you the first sentence of the op-ed you wrote in (link to op-ed) The New York Times recently. It said: “If I were a pregnant woman living on the Gulf Coast or in Florida in an impoverished neighborhood and city like Houston, New Orleans, Miami, Biloxi, Mississippi, or Mobile, Alabama, I would be nervous right now.”
Explain.
DR. PETER HOTEZ, Texas Children’s Hospital: Well, the reason I made that statement, Hari, was because what we know, where this terrible birth defect, microcephaly, is happening.
It happens when pregnant women are bitten by the Aedes mosquitoes. So, the first requirement is, it has to be a part of the world where we have the Aedes mosquito. And, also, the other component that not many people appropriate is both crowding and poverty.
And the reason why poverty is so important is because women who live in poverty have increased exposure to mosquitoes because of absent — or broken window screens, collected garbage, environmental degradation near the home that breeds mosquitoes.
And so what you have on the Gulf Coast of the U.S. is the perfect storm of all three factors, the Aedes aegypti mosquito, the extreme poverty and crowding, that you would find in Northeastern Brazil, which is the epicenter of this epidemic or what we have seen moving into Colombia.
So, for all the reasons we’re seeing microcephaly cases appear in Brazil and Colombia, I believe we’re going to see on the Gulf Coast, especially as we move into the warmer months, when our mosquito numbers start to rise.
So we’re already finding Aedes aegypti mosquitoes on the Gulf Coast, including here in Houston. But I’m very worried that as we go into the warmer months, those mosquito numbers are going to incline, with it, the poorer neighborhoods on Gulf Coast cities, such as Houston, New Orleans, others, are really going to be affected by Zika.
HARI SREENIVASAN: So, what’s that timeline of progression that you see? Not all mosquitoes have Zika. It will take some time for some of them to get Zika, and then some of them to bite people, some of those people to have symptoms, some of those symptoms to be severe.
DR. PETER HOTEZ: Well, arboviruses, viruses transmitted by mosquitoes are not new to the Gulf Coast. We have experienced a number of epidemics of arboviral infections.
For instance, in 2003, Houston experienced an epidemic dengue fever caused by the same Aedes aegypti mosquito. And what we found was, those numbers started to rise in May and into June, and with it, we then started seeing a dengue outbreak back in 2003.
SUMMARY: A new study by the American Academy of Pediatrics shows that reading daily to young children, starting in infancy, can help with language acquisition and literacy skills. But, the report says, many children are missing out. Jeffrey Brown takes a closer look at the consequences and opportunities to improve with lead author of the study, Dr. Pamela High of the American Academy of Pediatrics.
JUDY WOODRUFF (NewsHour): Nearly 16 million children in this country don’t always have access to the food they need. A growing body of research indicates, the younger they are, the more serious the long-term impact can be, a key concern, making sure the very youngest and pregnant women are getting the proper nutrition.
Starting in 2010, a program under the health care reform law made that idea more of a possibility in many states.
Hari Sreenivasan has our report on one effort in Northern Arkansas.
HARI SREENIVASAN (NewsHour): Tori Moon always thought life on her own would look different than this. At 20, she lives in a budget motel in Harrison, Arkansas, eats donated food when it’s available and is now several months pregnant. Without much family in the area and a fiancé who works long hours, she spends much of her time feeling alone.
TORI MOON: It was really hard for me to make friends, being pregnant, because we live in the Bible Belt, and a lot of people around here don’t believe in being pregnant before marriage.
HARI SREENIVASAN: But Moon can count on at least one person dropping by regularly.
Every other week, Deena Tougaw sits down with Moon to discuss ways of staying healthy during pregnancy.
When scientists made the stunning announcement last year that a baby born with H.I.V. had apparently been cured through aggressive drug treatment just 30 hours after birth, there was immediate skepticism that the child had been infected in the first place.
But on Wednesday, the existence of a second such baby was revealed at an AIDS conference here, leaving little doubt that the treatment works. A leading researcher said there might be five more such cases in Canada and three in South Africa.
And a clinical trial in which up to 60 babies who are born infected will be put on drugs within 48 hours is set to begin soon, another researcher added.
If that trial works — and it will take several years of following the babies to determine whether it has — the protocol for treating all 250,000 babies born infected each year worldwide will no doubt be rewritten.
“This could lead to major changes, for two reasons,” said Dr. Anthony S. Fauci, executive director of the National Institute for Allergy and Infectious Diseases. “Both for the welfare of the child, and because it is a huge proof of concept that you can cure someone if you can treat them early enough.”
The announcement was the third piece of hopeful news in two days about the virus that causes AIDS.
On Tuesday, scientists reported that injections of long-lasting AIDS drugs fended off infection in monkeys, and on Wednesday, researchers announced a “gene editing” advance that might enable immune cells to repel the virus.
The first infant to make an apparent recovery from H.I.V. infection, now famous as the “Mississippi baby,” was described last March at the Conference on Retroviruses and Opportunistic Infections, the same annual meeting where the new case was reported on Wednesday.
The Mississippi child, now more than 3 years old, is still virus-free, said Dr. Deborah Persaud, a virologist who has run ultrasensitive tests on both children in her lab at the Johns Hopkins Children’s Center in Baltimore.
The second baby, a girl born at Miller Children’s Hospital in Long Beach, Calif., is now 9 months old and apparently free of the virus that causes AIDS.
Her mother, who has advanced AIDS and is mentally ill, arrived in labor; she had been prescribed drugs to protect her baby but had not taken them.
Four hours after the birth, a pediatrician, Dr. Audra Deveikis, drew blood for an H.I.V. test and immediately started the baby on three drugs — AZT, 3TC and nevirapine — at the high doses usually used for treatment of the virus.
The normal preventive regimen for newborns would be lower doses of two drugs; doctors usually do not use the more aggressive treatment until they are sure the baby is infected, and then sometimes not in the first weeks.
“Of course I had worries,” Dr. Deveikis said in an interview here. “But the mother’s disease was not under control, and I had to weigh the risk of transmission against the toxicity of the meds.”
“I’d heard of the Mississippi baby, I’d watched the video,” she added. “I knew that if you want to prevent infection, early treatment is critical.”
The Long Beach baby is now in foster care, she said. The mother is still alive as well.
It is incorrect to describe the baby as “cured” or even as “in remission” because she is still on the drugs, Dr. Persaud said. But because the most sensitive blood tests can find no virus capable of replicating, she describes the baby as “having sero-reverted to H.I.V.-negative.”
Both DNA and RNA of the virus were found in the baby’s early blood and spinal fluid samples, so Dr. Persaud said it was virtually certain she was infected at birth. The virus began to disappear six days after birth and was undetectable within 11 days.
It is considered medically unethical to stop the baby’s drugs now, but Dr. Deveikis and Dr. Yvonne J. Bryson, a pediatric AIDS expert at the University of California, Los Angeles, who is also working on the case, said they would consider stopping them briefly to see what happens if the baby is still virus-free at age 2.
Dr. Bryson is one of three investigators who will lead the clinical trial seeking 60 babies.
Obstetricians and pediatricians in the United States, South Africa and Brazil will be alerted to watch for babies being born to mothers who have not taken drugs to prevent mother-child transmission and to get them on full antiretroviral treatment immediately, even before the first blood test has been finished. (In the United States, fewer than 200 children each year are born with H.I.V.)
The trial will be funded by Dr. Fauci’s institute and be part of the Impact series of trials concentrating on preventing viral transmission to newborns.
“When we described the Mississippi baby, we were met with some skepticism,” she said. The Long Beach baby “was definitely infected.”
The Mississippi baby was born to a mother who got no prenatal care and was unaware that she was infected. Worried doctors at a local hospital transferred the baby to the University of Mississippi Medical Center, where a pediatrician, Dr. Hannah B. Gay, started aggressive antiretroviral treatment about 30 hours after birth.
Then, 18 months later, the mother stopped taking the baby to appointments and stopped giving the drugs. Five months later, when she came to an appointment, doctors feared the baby would be teeming with virus.
Instead, to their astonishment, they found none. And Dr. Persaud’s testing has found none, despite using tests normally able to detect dormant virus in adult patients on successful treatment.
Although antiretrovirals prevent the virus from replicating, a small amount usually persists in reservoirs throughout the body, integrated into the DNA of cells. Dr. Persaud’s test can activate those cells and force them to “spit out” the virus, where it can be detected.
Dr. Steven G. Deeks, an AIDS expert at the University of California, San Francisco, said the Long Beach baby offered more convincing evidence that starting therapy virtually at birth seems to kill the virus before it establishes a permanent reservoir.
“But it sure would be nice to have a way to decide when to stop” the treatment, he added. “That’s the next question.”
On July 10, my wife gave birth to a seemingly healthy baby boy with slate-blue eyes and peach-fuzz hair. The pregnancy was without complications. The delivery itself lasted all of 12 minutes. After a couple of days at Greenwich Hospital in Connecticut, we were packing up when a pediatric cardiologist came into the room.
We would not be going home, she told us. Our son had a narrowing of the aorta and would have to be transferred to the neonatal intensive care unit at New York - Presbyterian Hospital at Columbia, where he would need heart surgery.
It turned out that our son was among the first in Connecticut whose lives may have been saved by a new state law that requires all newborns to be screened for congenital heart defects.
It was just by chance that we were in Connecticut to begin with. We live in New York, where such tests will not be required until next year. But our doctors were affiliated with a hospital just over the border, where the law took effect Jan. 1.
As we later learned, congenital heart problems are the most common type of birth defect in the United States. The Centers for Disease Control and Prevention estimate that about one in 555 newborns have a critical congenital heart defect that usually requires surgery in the first year of life.
Many cases are caught in prenatal ultrasounds or routine newborn exams. But as many as 1,500 babies leave American hospitals each year with undetected critical congenital heart defects, the C.D.C. has estimated.
Typically, these babies turn blue and struggle to breathe within the first few weeks of life. They are taken to hospitals, often in poor condition, making it harder to operate on them. By then, they may have suffered significant damage to the heart or brain. Researchers estimate that dozens of babies die each year because of undiagnosed heart problems.
The new screening is recommended by the United States Department of Health and Human Services, the American Heart Association and the American Academy of Pediatrics. Yet more than a dozen states — including populous ones like Massachusetts, Pennsylvania, Florida, Georgia, Wisconsin and Washington — do not yet require it.
The patchy adoption of the heart screening, known as the pulse oximetry test, highlights larger questions about public health and why good ideas in medicine take so long to spread and when we should legislate clinical practice.
Newborns are already screened for hearing loss and dozens of disorders using blood drawn from the heel. The heart test is even less invasive: light sensors attached to the hand and foot measure oxygen levels in the baby’s blood. This can cost as little as 52 cents per child.
Our son’s heart defect was a coarctation of the aorta, a narrowing of the body’s largest artery. This made it difficult for blood to reach the lower part of his body, which meant that the left side of his heart had to pump harder.
In the hospital, though, he appeared completely healthy and normal because of an extra vessel that newborns have to help blood flow in utero. But that vessel closes shortly after birth, sometimes revealing hidden heart problems only after parents bring their babies home.
Depending on the heart defect, the onset of symptoms can be sudden.
This is what happened to Samantha Lyn Stone, who was born in Suffern, N.Y., in 2002. A photograph taken the day before she died shows a wide-eyed baby girl lying next to a stuffed giraffe. The next morning, her mother, Patti, told me, she was wiping Samantha’s face when she heard a gurgle from the baby’s chest.
Before her eyes, Samantha was turning blue. Blood began to spill from her mouth. Ms. Stone dialed 911, and minutes later, a doctor who heard the call over a radio was there performing CPR. Samantha went to one hospital and was flown to another.
But the damage was irreparable. Samantha had gone 45 minutes without oxygen: She lapsed into a coma and died six days later.
It wasn’t until several years later that Ms. Stone learned about the pulse oximetry test. “This could have saved my daughter,” she told me. “There is no parent that should ever have to go through what I went through.”
Pulse oximetry is not a costly, exotic procedure. Most hospitals already have oximeters and use them to monitor infants who suffer complications. You can buy one at Walmart for $29.88.
A recent study in New Jersey, the first state to implement the screening, estimated that the test cost $13.50 in equipment costs and nursing time. If hospitals use reusable sensors similar to those found on blood-pressure cuffs, the test could cost roughly fifty cents.
As medical technology advances, few screenings will be so cheap or simple. Recent years have seen controversy over prostate cancer and mammography screenings. Medical ethicists have to weigh the costs of each program and the agony caused by a false positive against the lives saved.
But with pulse oximetry, the false positive rate is less than 0.2 percent — lower than is seen for screenings newborns already get. The follow-up test is usually a noninvasive echocardiogram, or an ultrasound of the heart. A federal advisory committee came down in favor — three years ago.
“There’s really no question, scientifically, this is a good idea,” said Darshak Sanghavi, a pediatric cardiologist and a fellow at the Brookings Institution. “The issue is, how do we change culture?”
Opposition has taken two forms. One is from doctors who believe policy makers shouldn’t interfere with how medical professionals do their jobs. The other is from smaller hospitals, which worry about access to echocardiograms and the costs of unnecessary transfers.
These concerns can be addressed fairly easily. Nurses in New Jersey and elsewhere have been able to work the test into their normal routines. A rural hospital should already have a protocol to transfer a newborn in serious condition. If Alaska can do it, less remote states can, too.
But this is not simply a rural health care problem. Cardiologists and neonatologists I’ve spoken with said they knew of hospitals in New York City, Boston and metropolitan Atlanta that weren’t screening newborns for heart defects.
“It’s completely the luck of the draw of where you deliver,” said Annamarie Saarinen, who has pushed for the screening since her daughter narrowly avoided leaving the hospital with an undetected heart defect.
Fortunately, our son’s condition was also caught and corrected. The only lasting effects are a three-inch scar on his side and checkups with a cardiologist. He will live a normal life. He will be able to play sports and climb things he’s not supposed to.
Shouldn’t every baby have that chance?
