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Answering the Call for Pediatric Specialty Care in the Wake of Zika and Two Hurricanes

Shana Godfred-Cato, DO, FAAP
June 8, 2018


I peered out the window of a small Cessna during the 40-mile flight between St. Thomas and St. Croix in the U.S. Virgin Islands. With lush green hillsides rimmed by white sand beaches, crystal- blue waters, and acres of coral reef, the territory looked every bit the picture-perfect Caribbean paradise.


It was hard to imagine the people who lived here were dealing with the after-effects of two Category 5 hurricanes last fall, which came during the second year of a Zika virus outbreak. The territory, with just 133 total square miles of land and a population a tenth the size of Rhode Island’s, had 1,032 reported cases of infection since January 2016.


I was here as part of team of pediatric care providers requested by the U.S. Virgin Islands (USVI) Department of Health to help respond to health and developmental needs for a growing number of children born to mothers who tested positive for Zika virus infection. The spread of the mosquito-borne virus dropped off the later part of last year, but Zika-exposed babies may have lasting health needs caused by prenatal exposure to the virus. These include conditions such as microcephaly that often are apparent at birth, as well as other neurological and physical abnormalities can interfere with a child’s health and development over time.

 

The USVI health department knew children born to Zika-positive mothers did not all have access to the recommended screenings and follow-up care. They also knew specialty services were not optimal, especially as the territory continued to recover from the hurricanes. Our team’s goal was to help families avoid the need to leave the islands and their homes to get the assessments and care they needed. Instead, we’d bring medical specialists to them.


The Zika Health Brigade was born from cross-agency efforts led by the USVI Department of Health and Centers for Disease Control, with technical assistance provided by partners that included the U.S. Health Resources and Services Administration and American Academy of Pediatrics (AAP). The team included pediatric ophthalmologists, neurologists and audiologists, along with developmental pediatricians and other child health experts.



A 2-year Zika outbreak in the U.S. Virgin Islands has dropped off, but babies exposed to the virus need ongoing screening & care. Accessing pediatric specialists on the islands, recently battered by 2 hurricanes, isn’t easy, Dr. Shana Godfred-Cato writes in #AAPvoices

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The brigade was initially planned for the summer 2017, but Hurricanes Irma and Maria disrupted those plans by causing significant damage to much of the territory, including the Department of Health clinics. Instead, the brigade took place March 19-24, 2018.


We arrived at the airport in St. Thomas, the site of our first brigade clinic, and saw temporary blue tarps laid over roofs and construction underway to repair hurricane damage. A beautiful sunset colored the horizon as we drove to our hotel on a winding road that passed the island’s only hospital. Damage was evident, but several floors were open for operation. Cruise ships docked the shore, and tourists milled about the square where they purchased local fares. Here and on St. Croix, the larger island where we set up the next clinic, it was encouraging to see the local economy slowly picking itself back up after such devastation.


Determining and meeting the needs of children exposed to the Zika virus clearly would take longer, however. We formed a team with local health department staff and developed protocols to screen all patients and accurately record our findings. The protocols were shared with CDC and local providers to use for future screenings.


The hurricanes displaced many families, either temporarily or permanently. Some lost homes or jobs because of the damage, while others left to seek medical care that was not accessible in the territory. Internet, email and many phone lines were still down. To find women and invite them to bring their babies for screening, we called multiple phone numbers, sometimes reaching out to extended family members to help. To find pediatric care providers, we had gone door-to-door, connecting personally with every provider to educate the physicians on our goals for the health brigade and gather support to assist with recruitment of patients for the health brigade.



"Our team's goal was to help families avoid the need to leave the islands and their homes to get the assessments and care they needed. Instead, we'd bring medical specialists to them."

On this trip, the team screened 91 infants whose mothers were positive for Zika when they were born. There were a few infants that did have the phenotype of congenital Zika virus syndrome, but we excitedly found that most did not exhibit microcephaly or vision and hearing loss. There were a substantial number of infants who had some mild developmental, speech, or motor delay, but we are unsure whether that was caused by Zika virus exposure in utero or a result of families needing to focus so much time and energy on hurricane recovery.


Children in the territory will need continued visual, audiological, neurological and developmental support. Zero to Three, a family-based child development program, will be used extensively for these children. Beyond the toddler years, they will need to transition to alternative services. There are some adult specialists on the islands willing to assist with follow-up, and some pediatric providers that travel between the territory and the mainland to provide care. But these patients, as well as many others in the territory, need more access to pediatric care. We hope over time their provider list will continue to grow.


We plan to continue working with the USVI Department of Health as doctors in the islands continue to evaluate and support children and their developmental needs. The families we worked with were happy to be able to receive medical care without traveling off island, leaving their home regions and extended families.


The close-knit families who form the backbone of the islands, no doubt, will play a big role in overcoming the challenges the territory has faced these past couple years. I, for one, left deeply grateful to play a small part in helping these families stay together as they access care and support they need for their children.


Special Thanks To: Laura Aird, MS; Tracy Ambrose; James Bale, MD; Cara Biddle, MD, MPH, FAAP; Michelle S. Davis, DO, FAAP; O'Neill D'Cruz, MD; Roberta DeBiasi, MD, MS, FAAP; Sean Diederich; Esther Ellis, PhD; Nicole Fehrenbach, MPP; Romeo R. Galang, MD, MPH; Monica Halbert; Janney Hawley, RN; Braeanna Hillman, MD, FAAP; Ricky House; Amy Hudson; Cristie Jones, AuD, CCC-A; Ashley Kilpatrick, CCLS, SIMI; Nicola Kim, MD; Daniel Lattin, MD; Linda Lawrence, MD; Charmaine Mayers; Trevena Moore, MD, MPH, FAAP; Sarah Mulkey, MD, PhD; Mary Noe; Sarah Payne, MD; Derval Petersen, DHEd, MAOM; Grace Prakalapakorn, MD; Andra Prosper; Megan Reynolds; Dan Schoelles; Harris Short; Lessely Shuler-Brown, RN,MSN, MHSM,CLNC, CRN-C; V. Fan Tait, MD, FAAP; Yvonne Thomas; Deb Waldron, MD, MPH, FAAP. 


The views expressed in this article are those of the authors, and not necessarily those of the American Academy of Pediatrics. 

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​​​Ab​out the ​​Author


Shana Godfred-Cato, DO, FAAP, liaison to the AAP Disaster Preparedness Advisory Counsel for the Section on Early Career Physicians, serves as a contractor to the Centers for Disease Control and Prevention National Center for Birth Defects and Developmental Disabilities focusing on Zika. She assisted in the development of the updated Interim Guidance for the Diagnosis, Evaluation, and Management of Infants with Possible Congenital Zika Virus Infection. A general pediatrician practicing with the Austin Regional Clinic in Kyle, TX, Dr. Godfred-Cato also serves as a Major in the Texas Army National Guard. 

 







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