Role of Physical Therapy in a Triage Center During the Zika Virus Epidemic

In 2016, the World Health Organization (WHO) declared a global public health emergency following the dramatic and widespread emergence of Zika Virus (ZIKAV) in Brazil. An association of ZIKAV with congenital microcephaly (CM) was established.1 Up to 80% of those infected are asymptomatic, and when symptoms do occur, they are typically mild and can include cutaneous rash, arthralgia, conjunctivitis, and a low fever.2,3 But when transmission of the virus occurs during pregnancy, the effect on the fetus can be catastrophic. The Centers for Disease Control and Prevention has since created the term “congenital Zika syndrome” to refer to the most severely affected infants.4 The syndrome typically includes 5 distinctive features: severe CM, brain abnormalities, ocular findings, congenital contractures, and neurologic impairments.5 Others have reported neurological sequelae that include dysphagia, sensorineural hearing loss, epilepsy, and abnormalities of tone or movement, including hypertonia and signs of extrapyramidal involvement.6,7 These clinical consequences can have harmful effects on infant development and significant implications for rehabilitation practitioners involved in their care. Landry et al8 described the association of ZIKAV with CM, and recent studies have added vast knowledge to the epidemiology of ZIKAV. However, studies of the clinical manifestations, consequences, and management continue to be desperately needed. Rio de Janeiro is the third most populated metropolis in South America9 and one of the most visited cities in the Southern Hemisphere.10 Brazil’s most popular tourist destination faces difficulties associated with its high poverty rates. Numerous issues have plagued the region, including political unrest, poor sanitation, and, most recently, the ZIKAV epidemic. In a city with some of the most scenic views in the world, one may be surprised to learn that 34% of the population does not have access to sewage collection.11 The infant mortality rate is 11 per 1,000 live births, which is twice as high as the United States.12,13 The average family earns the equivalent of 5000 US dollars per year.14 High poverty levels foster sanitation problems, such as stagnant water where the Aedes mosquitoes can breed.15 In 2016, the outbreak of ZIKAV in Rio de Janeiro led local authorities to declare it an epidemic. Brazil has one of the largest publicly funded health care systems.16 It is free, wide ranging, and covers the entire population (210 million people).17,18 However, it operates in a perpetual state of crisis and management flaws and lacks investment. As a result, the system is unable to provide adequate care. In Rio, most public hospitals operate far beyond their capacity. Staff regularly work without timely paychecks, and basic equipment, from gauze to bedsheets, is often lacking. Despite these challenges, in 2013 the Instituto Estadual do Cérebro Paulo Niemeyer (IECPN) was established in Rio as the only public hospital in Brazil dedicated entirely to high complexity neurosurgery. Three years later, during the epidemic, it was designated by the government as the official interdisciplinary evaluation center for the screening of children with CM in the state. The additional charge resulted in several substantial and unforeseen challenges. Physical therapists played a key role in patient evaluation during the peak of an epidemic caused by an emerging disease about which little was known. Through a comprehensive examination of the infants, interdisciplinary professionals worked to identify CM associated with maternal ZIKAV infection to assess the individual needs of each child and to recommend specific treatment close to each family’s home. All children referred to IECPN either had CM at birth or were born to mothers who reported ZIKAV symptoms during pregnancy. The triage clinic served low-income families from both densely populated and rural areas of the state. Many families commuted long distances and lacked basic information about what to expect. The triage team included pediatrics, neuro-pediatrics, speech therapists, nurses, psychologists, social workers, and physical therapists. Appointments were scheduled over a period of 2 days and included imaging (electroencephalogram, head computed tomography scan, and/or magnetic resonance imaging), hearing, and eye exams, when indicated. A total of 4 pediatric physical therapists rotated shifts and assessed tone, affect, reflexes, gross motor development, and orthopedic alterations (Tab. 1). During the evaluation, therapists also provided families with information and handouts on early intervention. Demographic Characteristics and Measures Assessed at Intakea IQR = interquartile range; ROM = range of motion. A total of 250 infants were evaluated at IECPN from March 2016 to March 2017; 65% were microcephalic at birth. Standards for CM vary and have changed over time. For the purposes of this report, the current WHO Child Growth Standards for size at birth were used to interpret the cephalic perimeter measurements for term neonates (37–42 weeks) and INTERGROWTH-21 Standards for babies born preterm (<37 weeks).19 Of the 86 babies 4 months or older, 2 were missing data on cephalic perimeter. Of the remaining 84 babies, 60 (71%) were classified as having motor delays (according to Brazilian Ministry of Health Guidelines)20 and 51 (61%) had CM. Of those with CM, 39 (77%) also had motor delay. Interestingly, 21 (64%) of infants without CM at birth also had motor delay. These findings indicate that neurodevelopmental delay can present in normocephalic children with in utero exposure to ZIKAV. This has been documented in the literature.21 Thorough physical assessments, which can detect problems in the absence of CM, are therefore critical in this population. For the purposes of this report, motor delay was only reported in children who were 4 months or older at the time of evaluation. This is when the first motor milestone occurs, though potential delays were noted for most children. A total of 154 babies (62%) showed abnormal muscle tone: 133 were hypertonic (54%) and 21 were hypotonic (8%). Also, 23 babies (9%) had 1 or more orthopedic abnormalities (Fig. 1). Infant with characteristic microcephaly and wrist and foot orthopedic deformities. Setting up a triage center in addition to the normal routine of any hospital is demanding and requires extensive reorganization. Despite the circumstances, we strived to provide families in distress with emotional assistance, and as much clinical information as possible, in a short time. Each discipline had an average of 30 minutes to perform its specific evaluation. The sequence varied due to logistics and the infant’s feeding/napping schedule. It was up to the first examiner to answer the many questions and concerns from families. Due to the tight schedules, families would spend most of the day at the hospital and occasionally wandered away from the unit to eat, causing additional delays. Bouts of extreme irritability are commonly associated with babies infected by the ZIKAV,22 and, since the infants were on average 3 months old, with 16 of them just over a few weeks, the challenge to perform thorough physical exams was heightened. Our call-to-action is to highlight the importance of physical therapists as members of an interdisciplinary triage team during an epidemiological emergency. Physical therapists are not specifically trained for acute crisis situations; however, we provided critical evaluations of 250 children in 12 months and were able to influence the infants’ care by identifying specific problems that may not be routinely detected by other professions on the triage. In addition, the qualities that were most critical for the physical therapist team were those that most therapists use in practice every day, namely, possessing the flexibility and adaptation necessary to work with diverse families with a wide range of financial, psychological, and social needs. One of the primary discussions prior to opening the triage center was the choice of scale for developmental assessment. Time constraint prevented the use of the well-known Alberta scale that assesses motor performance but requires an average of 20 minutes to administer. Other scales that require previous training/certification or financial investments were not viable options. The extreme irritability of some of the infants prevented filming for post hoc evaluation. The guidelines utilized20 were useful, but a more sensitive tool for future analysis and comparison would have been best. Since hypertonia was the most common characteristic observed at the evaluation of the babies, using a specific spasticity scale to quantify the hypertonicity would have been valuable. At times, hypertonia was visible by postural observation but difficult to quantify due to the small size of the young limbs. Another limitation was the lack of blood tests confirming the ZIKAV infection specifically. The health care system was overwhelmed with responding to the emergency as well from a lack of financial and laboratory resources. Laboratory evidence of infection allows for definite proof that the mother was infected with the virus during pregnancy instead of relying on clinical manifestations and subjective symptomatology. For further epidemiological scientific understanding, this is crucial. Having had time to reflect on our work, we realize that the lack of specific financial support for a long-term action was our greatest shortcoming. It directly impacted the tools and means during the crisis and affected our ability to monitor the infants over time and reevaluate their development. Reevaluation and follow-up care with broader resources and skilled professionals would have provided a critical understanding of the communal impact of the disease and the individual need of each infant. Having physical therapists focusing on motor milestones addressed the main concern of parents: will their babies have motor delays? Despite the shortage of resources, it was still valuable for the families to receive critical information and to bring awareness to the importance of early intervention. The ZIKAV epidemic was a public health crisis in Brazil. The families will face challenges that can be overwhelming, even in countries with greater resources. The crisis, however, highlighted an important role that therapists can play in an interdisciplinary response. We hope to build on and learn from these efforts to improve our response to the next crisis. Perhaps our international colleagues can assist with similar efforts in the future, and perhaps we can be of help to others facing similar situations. Concept/idea/research design: R. Freire, C.H. Gaspari, L. Albuquerque, A.R. Darragh, M. Campo Writing: R. Freire, C.H. Gaspari, A.C. Jaccoud, A.R. Darragh, M. Campo Data collection: R. Freire, L. Albuquerque Data analysis: C.H. Gaspari, A.R. Darragh, M. Campo Project management: C.H. Gaspari Providing institutional liaisons: C.H. Gaspari Clerical/secretarial support: R. Freire, C.H. Gaspari Consultation (including review of manuscript before submitting): R. Freire, C.H. Gaspari, L. Albuquerque, A.C. Jaccoud, F. Fialho, A.R. Darragh Instituto Estadual do Cérebro Paulo Niemeyer. There are no funders to report. The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest. Part of the data was presented at the World Confederation for Physical Therapy Congress in Geneva, Switzerland, May 10–13 , 2019.

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