Trends of microcephaly and severe arthrogryposis in three urban hospitals following the Zika, chikungunya and dengue fever epidemics of 2016 in Jamaica

Abstract

Introduction: Jamaica experienced its maiden Zika virus (ZIKV) epidemic in 2016, while dengue (serotypes 3 and 4) and chikungunya were also circulating. Aim: We describe initial trends in microcephaly and arthrogryposis observed by the clinicians from three urban birthing facilities during late 2016 to early 2017. Methods: Reporting of infant microcephaly was required from all birthing facilities in Jamaica. Staff were to be trained in measuring the occipito-frontal head circumference (OFC) using World Health Organization's (WHO) standards. Affected newborns were to be referred for comprehensive paediatric evaluation. Results: Hospital A reported 15 full-term newborns with microcephaly, 10 were delivered between November 10, 2016 and January 6, 2017. All were full-term newborns with OFC ranging from 28.5 to 31.5 cms, severe microcephaly with OFC's < -2 Z score, six patients had OFC < 31.4 cms < - 2 Z scores) amongst symptomatic mothers during May 1, 2016 through March 31, 2017. Four others had low OFCs (< 33 cms), but not in the range for microcephaly. Therefore, 84% (36/43) of babies born to symptomatic mothers had a normal OFC. Microcephaly rate for all live births for the period was 2.2% (26/1180). The monthly rate varied from 0% to 5% (6/118) peaking in March. Of two babies referred with severe arthrogryposis and microcephaly, one had characteristic evidence on nuclear magnetic resonance imaging of corpus callosum dysgenesis, occipital lobe cyst, cerebellar hypoplasia and intra-cranial calcifications. In the other CT scan of the brain revealed microcephaly with cortical atrophy, severe ventriculomegaly of lateral and third ventricles, fine calcifications in the thalami and basal ganglia bilaterally and in the right frontal lobe, with a huge posterior fossa cyst communicating with the 4th ventricle. He died and autopsy confirmed these findings. Cross-reactivity of serological tests for dengue and Zika virus challenged laboratory diagnosis in mothers and newborns. Conclusion: Newborns with "characteristic CSAZ features" are being born in urban settings primarily to asymptomatic mothers in Jamaica. Diagnosis is challenged by serological cross-reactivity between the circulating flaviviruses. Team management is multidisciplinary and will be a costly intervention for developing countries to implement to maximize the neuro-developmental potential of this new and vulnerable population of children.