Update on Zika Virus and Guillain-Barré Syndrome

2/03/2016

A Rare Neurological Paralysis Disorder and another Challenge for ZIKV Affected Countries

GUILLAIN-BARRÉ SYNDROME (GBS)

Key Factors

Zika-Mosquito-200x200Guillain-Barré syndrome is a rare condition in which a person’s immune system attacks their peripheral nerves. In many cases there is a history of infection that causes the immune response in the nerves. People of all ages can be affected, but it is more common in adults and in males.

Most people recover fully from even the most severe cases of Guillain-Barré syndrome, but although less common and treatable, severe cases of the syndrome can result in near-total paralysis and death. Reportedly, between 3.5 and 12% of patients die from complications during the acute phase.

Several WHO Member States have reported important epidemiological data consistent with a temporal and spatial link between Zika virus (ZIKV) circulation and the increase of Guillain-Barré syndrome.

Given the increase of congenital anomalies, Guillain-Barré syndrome, and other neurological and autoimmune syndromes in areas where Zika virus is circulating, the Pan American Health Organization / World Health Organization (PAHO/WHO) recommends its Member States to:

  • Establish and maintain the capacity to detect and confirm Zika virus cases,
  • Prepare healthcare facilities to respond to a possible increased demand of specialized care for neurological syndromes,
  • Strengthen antenatal care,
  • Continue with their efforts to reduce the presence of mosquito vectors through an effective vector control strategy and communication to the public.

Medilink International advises its clients operating in Zika affected territories to strengthen vector control strategies and ensure that adequate medical support is in place to detect and treat suspect Zika virus cases.

Epidemiological Update

Guillain-Barré Syndrome and ZIKV

During the Zika virus outbreak in French Polynesia (2013-2014), 274 patients had presented neurological syndromes or auto-immune syndromes after the manifestation of symptoms consistent with Zika virus infection. Of these, 42 were classified as Guillain-Barré syndrome (GBS). Of the 42 registered GBS, 24 (57%) were male, and 37 (88%) had signs and symptoms consistent with Zika virus infection (1, 2, 3).

In July 2015, Brazil reported the detection of patients with neurological syndromes who had recent history of Zika virus infection in the state of Bahia. There were 76 patients with neurological syndromes identified, of which 42 (55%) were confirmed as GBS. Among the confirmed GBS, 26 (62%) had a history of symptoms consistent with Zika virus infection.

In addition, on 25 November 2015, the Aggeu Magalhães Research Center of the Oswaldo Cruz Foundation reported that ZIKV infection was found in 10 of the 224 suspected dengue patients whose samples were analyzed for Zika virus infection. Seven of the 10 samples analyzed corresponded to patients with neurological syndrome.

In January 2016, El Salvador reported the detection of an unusual increase of GBS since early December 2015. On average, El Salvador records 14 cases of GBS per month (169 cases per year), however, between 1 December 2015 and 6 January 2016 there were 46 GBS recorded, two of which died. Twenty-five (54%) were male and 35 (76%) were over 30 years old. All were hospitalized and treated with plasmapheresis or immunoglobulin. Of the deceased patients, one had a history of multiple underlying chronic diseases. In 22 patients whose information was available, 12 (54%) had febrile rash illness between 7 and 15 days prior to the onset of GBS.

Currently, similar situations are being investigated in other countries of the Americas. These findings are consistent with a temporal and spatial link between Zika virus circulation and the increase of GBS. Although the etiopathogenesis and associated risk factors have not yet been well established, Member States should implement surveillance systems to detect unusual increases in cases and prepare health services for care of patients with neurological conditions.

Case management

Guillain-Barré Syndrome

GBS treatment is symptomatic and supportive. Recovery can take several weeks or months and can often cause prolonged disability requiring rehabilitation by a multidisciplinary team (doctors, nurses, physiotherapists, etc.).

People with Guillain-Barré syndrome should be treated and monitored; some may need intensive care. Treatment includes supportive care and some immunological therapies. GBS patients are usually hospitalized so that they can be monitored closely.

Given the autoimmune nature of the disease, the treatment strategy used in the acute phase is immunotherapy, such as plasma exchange and intravenous immunoglobulin. Corticosteroids given alone do not significantly hasten recovery from GBS or affect the long term outcome.

The aim of plasma exchange is to remove from the bloodstream antibodies and replace them with artificial plasma, usually albumin. Plasma exchange is most beneficial when initiated within 7 – 14 days from onset of the disease.

Intravenous immunoglobulin hastens recovery, as does plasma exchange, and it is much easier to manage. It should begin within two weeks from the onset of symptoms.

Even under the best quality available medical care, approximately 5% of patients with Guillain-Barre syndrome die from complications such as sepsis, pulmonary embolism or unexplained cardiac arrest. Thus, these complications must be identified early by healthcare workers, with frequent monitoring of vital functions and prevention of pulmonary embolism.

Whenever possible, it is advisable that patients with Zika virus infection, suspected to have Guillain-Barré syndrome should always be treated in an intensive care unit in order to maintain continuous monitoring and to respond immediately to any urgency or signs of complications.

References

  1. Institut de Veille Sanitaire (InVS). Bulletin hebdomadaire international du 5 au 11 mars 2014. N°442. France : InVS ; 2014. Available at: http://www.invs.sante.fr/Publications-etoutils/Bulletin-hebdomadaire-international/Tous-les-numeros/2014/Bulletin-hebdomadaireinternational-du-5-au-11-mars-2014.-N-442
  2. European Centre for Disease Prevention and Control. Rapid risk assessment: Microcephaly in Brazil potentially linked to the Zika virus epidemic – 24 November 2015. Stockholm: ECDC; 2015. Available at: http://ecdc.europa.eu/en/publications/Publications/zikamicrocephaly-Brazil-rapid-risk-assessment-Nov-2015.pdf
  3. Millon P. Epidémiologie des syndromes de Guillain-Barré en Nouvelle-Calédonie entre 2011 et 2014 : influence des arboviroses. Faculte de Medecine de Grenoble: Universite Joseph Fourier; 2015. Available at: http://dumas.ccsd.cnrs.fr/dumas-01153577/document
  4. Brazil Ministry of Health. The public health Emergency Operations Center report on microcephaly. Epidemiological Week 1 of 2016. Brazil; 2016. Available at: http://portalsaude.saude.gov.br/images/pdf/2016/janeiro/13/COES-Microcefalias— Informe-Epidemiol–gico-08—SE-01-2016—Valida—-o-12jan2016—VALIDADO-PELOCLAUDIO–e-com-os-estados-por-webconfer–n.pdf
  5. Ventura C, Maia M, Bravo-Filho v, Góis Adriana, Belfort Jr R. Zika virus in Brazil and macular atrophy in a child with microcephaly. Correspondence. The Lancet. Enero 2016. Avaialable at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00006-4/abstract
  6. Brazil Ministry of Health. Microcephaly – Ministry of Health releases epidemiological bulletin [Internet]. Available at: http://portalsaude.saude.gov.br/index.php/cidadao/principal/agencia-saude/20805-ministerio-da-saude-divulga-boletim-epidemiologico
  7. McGrogan A, Madle GC, Seaman HE, de Vries CS. The epidemiology of Guillain–Barre Syndrome worldwide.Asystematic literature review. Neuroepidemiology. 2008 Dec 17;32(2):150–63.
  8. Yuki N, Hartung P. Guillain-Barré Syndrome. N Eng J Med. 2012 ; 366 : 2294-304. 9. WHO/CDC/ICBDSR. Birth defects surveillance: a manual for programme managers. Geneva: World Health Organization; 2014.
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