 I'm delighted to introduce today's speaker, a friend and colleague, Dr. Emily Landon. After graduating from Loyola University Stretch School of Medicine, Dr. Landon completed her residency fellowship and chief residency at the University of Chicago. She did her fellowship in infectious disease, and also in 2014, Dr. Landon completed her ethics fellowship at the McLean Center here. Dr. Landon is an assistant professor of medicine at the University of Chicago in the sections of infectious diseases and global health, and also an assistant director of the McLean Center. Dr. Landon also serves as our medical center's hospital epidemiologist and as medical director of the infection control program at the University of Chicago. Dr. Landon's research is focused on healthcare provider behavior, especially behavior modification aimed at reducing the risk of healthcare related infections. Many of you are aware of Dr. Landon's extraordinary work in improving hand hygiene here at the medical center. She's also interested in the ethics of quality improvement research and the application of public health ethics to prevent infections in the hospital setting. When the Ebola crisis hit the United States and globally, Dr. Landon became a national expert on ethics issues related to Ebola management and clinical management in the hospital setting. Dr. Landon's talk today is titled Ebola and Zika, Case Studies in Management of Infectious Diseases and Pregnancy. Please join me in giving Dr. Landon a warm welcome. I don't know if I can make it through a whole hour without talking about hand hygiene, but I'm going to try. I want to start by thanking everybody for inviting me to do this talk today. The speakers in this seminar have been particularly awesome, so I apologize in advance. I hope maybe the newsworthiness of Ebola and Zika will get over any other lacking things that might happen in my presentation. But some of you may be asking yourselves why we are talking about infectious diseases when we have made such an amazing impact on them over the past hundred or so years. It looks as though infectious diseases are off the radar. I mean, our surgeon general said in 1967, because infectious diseases have been largely controlled in the U.S., we can now close the book on them. It might have been a little bit preliminary. So it turns out that there are a lot of infections that we handle every day that affect the way that we think about taking care of patients, and they have a big impact on the way that we think about medical ethics, largely because they add to the stakeholders, the key stakeholders in any ethical decision. The sort of point that I want to make throughout this talk is that when we have a patient-doctor-diad relationship where we work through problems with patients and ethical, sticky situations, it's the entrance of third parties and additional stakeholders that make things difficult for us. And first of all, reproductive ethics involves this key stakeholder of the fetus, which we are not addressing the moral status of the fetus today. That has already been discussed. But one would argue that we also have that same issue in infectious diseases where we think about the health of the providers and the health of the other patients that may or may not be affected by these infections. And that erodes autonomy for the patient. And how we deal with that is an important question that we need to answer in ethics and in ethics in infectious diseases and reproductive medicine. It's a question that we have to answer when we make a decision about whether or not we should allow children in the waiting room of the labor and delivery triage area like we did yesterday, or it makes a difference in making a decision about how we're going to address things like Ebola and Zika. And so I'd like to talk a little bit about our experience with Ebola and Zika and connect that to how we handle things nowadays by talking just a little bit about HIV. And hopefully it will give us some ideas about how we can address some of these problems going forward. So first of all, Zika and Ebola are two very different infections, but they matter to us for two very different reasons. And so let's contrast just a little bit to start out with. Ebola, there's a lot of person to person transmission with Zika, not so much. There's sexual transmission of both infections and maybe prolonged even after the patient is well. They may be able to pass it on sexually. There is not mosquito transmission with Ebola, but there is of course with Zika. The mortality rate far higher with Ebola, far lower with Zika, but the problem with pregnancy outcomes in Ebola, there is almost certain fetal demise. But in Zika, there is a long term problem in the outcome of the fetus that we aren't even completely aware or understand how that's going to affect future generations. Asymptomatic infection is incredibly rare with Ebola, but very common with Zika. And these specific differences make a big changes to make big changes to how we focus on addressing these infections both from a clinical standpoint and probably from an ethics standpoint as well. So let's talk a little bit about how the extra weight on the scale of ethical decision making comes into play when we add in these additional stakeholders. So in medical ethics, we really focus on the individual in front of us. We're really worried about treating illness, about respecting patient autonomy, about diagnosing and treating things and maintaining patient confidentiality. But when we talk about epidemiologic ethics, we're really focused on population health, preventing illnesses, worried about justice, investigating and changing things for the better, and we favor reporting for others' protection. When you're taking care of a patient with an infectious disease, you are not just the doctor or patient dyad that you always are worrying about medical ethics, but you have to, to a certain degree, take on the mantle of being someone who dabbles in epidemiologic ethics and think about those things as well and how we balance them matters. So in pregnancy, Ebola, as you know, much about is a terrible disease that causes a lot of mortality and morbidity. A fetal infection occurs via the placenta and Ebola can remain in the amniotic fluid even after viral clearance from the blood. Pregnant women with Ebola are at increased risk as opposed to regular old pregnant women, not as opposed to other people with Ebola. But pregnant women with Ebola are at increased risk of spontaneous abortion, pregnancy-related hemorrhage, still birth and death. The question about whether or not pregnant women with Ebola have worse outcomes than people with Ebola is still left unanswered, many would say biologically plausible that, yes, they do have worse outcomes. Fetal or neonatal death has occurred in 100% of the known pregnancies of women that have tested positive for Ebola who are known to be pregnant. The baby has died either as a fetus or shortly early in the neonatal period. And so we have no surviving children of women with Ebola. However, maternal survival is in fact possible and we know, probably, if they receive good care, but sometimes that means both infectious disease care and support and obstetrical care. And that can be really difficult. So there are very poor outcomes in Africa for both moms and the fetus. And this is largely because the way of isolating patients in Africa is to put them in an Ebola unit. There's much less isolation capacity. They use what we would prefer to as cohorting as opposed to isolation. So all the patients with an infection are put together. And so a woman with Ebola who is pregnant needs to make a decision if they are going to the Ebola unit or if they are going to the obstetrics unit. And anyone with confirmed Ebola is going to the Ebola unit, where there is no obstetrical care available. And so there's no cesarean delivery. Even if you could do them, the throws of DIC can make things very difficult for mom and the providers. And vaginal delivery itself is very messy and fluid producing. And we know that obstetrics providers are at much higher risk of any blood borne pathogen than almost any other specialty. So when we talk about doing things differently here in the United States, we have our way of thinking about the Ebola Risk Benefit Balancing Act, which is what I call it, but really refers to any infectious disease. You have the risk to the patient, potential benefit to the patient, and the patient gets to choose how that scale measures out for them. It doesn't happen in the case of infectious diseases. And Ebola is a good example. All of a sudden you have risk to providers, risk to other patients. That woman that may or may not have Ebola yet, you haven't decided. If you put her on the obstetrics unit, she's going to expose every single other woman on that unit. And the healthcare providers, no matter how much PPE they wear, will be at higher risk because that PPE that they have in resource poor settings isn't quite the same as what we have here. And so now we don't just have patient preference weighing in on this scale. We have provider preference and public health preference eroding away the patient's autonomy. And we may say that that's acceptable in the throes of a massive outbreak and a pandemic in a country where there are very few healthcare settings, that it's expected that some people are going to have a higher likelihood of dying than they would if they had better medical care. That is true of all the patients that were in the Ebola treatment centers in Africa. But here in the United States, we might be able to do things a little bit differently. So it was surprising to me when as our Ebola medical specialist here, I read the ACOG practice advisory that recommended for patients with Ebola. It's prudent to avoid the usual obstetric interventions like fetal monitoring, cesarean delivery, induction, surgical repair, oblacerations in this select group of extremely women. I agree with that statement. It may in fact be prudent to do those things or to forego those things. However, it goes on to say that for all women with Ebola virus disease, there will be a window in which Ebola virus disease is suspected, but has not been confirmed with laboratory testing. These women should be treated in a similar fashion to that described above, recognizing that a portion may prove negative. Unfortunately, when a woman presents to a clinic with symptoms of either Ebola or a pregnancy-related complication, the window period in which it takes to get the test results back is often the same period in which that baby is either going to die or be delivered. So some thoughts about what we've learned about Ebola. Over 10,000 people in the United States were monitored for Ebola during the fall and winter of 2014, with people that entered the country having been in Western Africa. More than 400 people were tested for Ebola in the United States. Some of those were about 40 of them came from that 10,000 people who were monitored. The others were people who were identified as being ill on arrival to the country and were put into hospitals like ours to be ruled out or ruled in for Ebola. 11 of those people tested positive, meaning that greater than 97% of the tests done for Ebola were negative. These are people who were just in Western Africa, potentially had exposure to people with Ebola and 97% of them and presented with an illness and 97% of them didn't have Ebola. That's a very low pre-test probability of testing positive for something. And yet pregnancy complications in Ebola present in almost the same way. Bleeding, abdominal pain, fever, vomiting, miscarriage or fetal death or concern for such. These are the things that people come to. These are obstetrical emergencies and they are also Ebola. Yet obstetrics, as we said before, is a very high risk occupation. So actually, I think, I wanted to know who said this. But because I'm missing notes here. But the question of whether or not Dr. Black, I guess, asked the question, is it ethically justifiable to withhold potentially life-saving treatment to someone who is suspected of having an infectious disease? And also, is it ethically justifiable to risk exposing health care providers and patients by admitting and caring for a patient that's suspected of having an infectious disease? And these questions are very difficult to answer in the case of a woman presenting in Guinea. But they're a lot easier for us to answer here in the United States. Because the weight of the fear and the weight of the issue of potentially exposing other patients and other health care providers can be modified with the resources that we have available to us. Fear is very different from reality. And so at the University of Chicago, we took the tack that the right thing to do was to minimize the amount of effort we had, or the amount we had to encroach upon individual patient liberties by doing things like mitigating the risk to providers and mitigating the risk to other patients. For example, we use PPE that is beyond extreme. This is an example of an outfit, Sylvia, wearing the PPE outfit that we expected. The PPE for a potential delivery includes another cover over that goes from head to toe with only like a shield in the front, a second layer of PPE that can just be sort of sloughed off because we expected so much fluid contamination. We can train people in this PPE. We can give them simulation-based training where they get the chance to become more facile and more comfortable and more confident in wearing these things. We can also plan ahead by telling patients, by planning what we're going to curtail in terms of their autonomy. By saying, we will allow you to make a decision about whether or not you want to be intubated, but that decision will have to be made when it's elective. So we will make, we will intubate you when it's an elective semi-urgent, but we don't want to do an urgent or emergent intubation. We will allow you to choose dialysis, but you're gonna get CVVH. You can't choose intermittent hemo dialysis because it's not taking you off and on the miscine is riskier. And so there were things that we can do to help mitigate the risk, but allow patients to maintain some sense of autonomy and decision-making about what treatment limitations they'd like to impose on themselves. Now some things are impractical. You can't let a patient with Ebola use an MRI scanner because we only have a few of them and it would take days for it to be ready for any other patient to be able to use it again. And the transport routes couldn't be made safe or sort of closed in in order to allow other people to use that area. So clearly there were some things that were off the table, but we wanted to put as much onto the table as possible. We also recognize that rule out patients are very different from confirmed Ebola patients. Not just because the pretest probability of them ruling out was so high, but also because patients earlier in their infectious disease process with Ebola are far less infectious. The infectiousness of Ebola increases as the disease progresses, and then it comes back down again. So patients who are in this rule out period are by definition less infectious and almost not likely to have Ebola. And so we could be a lot more aggressive with taking care of them when they were in this before we knew about their Ebola status. Careful weighing the risk and benefits was essential. And our plan here was to be able to provide almost as much as to be ready with the supplies and the equipment and the training needed to provide any obstetrics needs that need to happen for these patients with the decision that we could make the complex decision making based on individual patient desires and individual preference of the providers based on the clinical situation at hand with support from ethics and other experts. So that's how we handled Ebola at the University of Chicago, although we never got to be tested with a pregnant Ebola patient, no one in the United States did, which is both good and bad because I suspect we would find the outcomes are somewhat better as we did for the rest of Ebola if you have the highly supportive care of an institution like the University of Chicago. Switching gears to talk about something completely different, Zika. And first I wanted to go over a few specific details about Zika because I think it's less well known to the audience here and so I'm sorry if I'm boring you. But Zika is a flavivirus that's similar to dengue and chikungunya. It can cause fever, conjunctivitis, headache and joint pain and skin rash. You get sick about two to seven days after your exposure and most people are just fine. In fact, 80% of people have no symptoms at all and almost no one actually dies of Zika virus. In the person who actually gets the disease, it's no big deal. However, if you're pregnant, it can be a very, very big deal for the baby. It's carried by 80s Egypti mosquitoes, most effectively by 80s Egypti mosquitoes, also mosquitoes that carry dengue and chikungunya and you can see the distribution of 80s Egypti mosquitoes. But lest you think we are safe here in Chicago, it has also been found although less effectively carried, it can be carried by the 80s albapictus mosquitoes as well, the Asian tiger mosquito which we do have in this area. And that's just some basic information. So this is where we've seen Zika. These are all the countries that have reported cases of Zika recently. And I will say that the very first time that Zika was discovered was in a gorilla in the Uganda Zika forest in 1947. The first outbreak was known to us, was in 2007 in the Pacific Island of Yap where 73% of the population was affected by Zika. And in 2013 and 14, there were about 28,000 cases in French Polynesia. And that's the history of what we have about Zika. And we knew from then that there might be some issues with fetal outcomes in women that were pregnant at the time that they had Zika. So how do we test for Zika? We do nucleic acid amplification testing of serum and urine. It's recommended to do up to two weeks after symptom onset, but sooner is better for those of you who are wondering within one week is much better than two weeks, but you can do it up to two weeks. And if you have, we'll get to the recommendations in a minute, but less than two weeks after the last known exposure for an asymptomatic woman who wishes to be tested. And those women who live in areas with endemic Zika or epidemic Zika do need to have more complicated testing regimen that I'm not going to go into. Surrology is available, but with the caveat that there is a lot of crossover between Zika serologies, dengue, and chikungunya, and it can be very difficult to figure out which infection the patient actually had. And so you had something. The real issue with Zika is the concern from microcephaly. So there are initial reports of an increase in microcephaly cases in northern Brazil is what led to the concern about this virus that otherwise wouldn't have really come on the radar because people don't get very sick from it. And it turns out that since those initial concerns, there have been some very robust case control and some very early cohort studies that have described a link between Zika and microcephaly. The odds ratios in the Lancet ID case control preliminary analysis show about 55 with a 95% confidence interval that goes to infinity for microcephaly and lab confirmed Zika. And the correlation is even higher for patients that have babies that have typical CT changes and positive tests for Zika in either the mom or the baby at some point. Turns out that microcephaly is only one piece of what is now being referred to as the congenital Zika syndrome, where you have the severe microcephaly with partially collapsed skull that you saw in the previous picture. There's also a specific pattern of brain damage and decreased brain tissue that it turns out may not be present at birth but can evolve over time in the neonatal period. And so one single time of screening for a newborn baby that has been exposed may not be enough. There's also retinal damage, some joints with limited range of motion and hypertenicity in the newborn. But the bottom line is we don't really know what the entire spectrum of disease is. It's expected that we will find that even children that some children who appear to be normal at birth may suffer from intellectual disabilities down the line. And that's a level of uncertainty that makes it very difficult for us to predict and decide what to do. So there have been a number of Zika cases in the United States. Every state except for Alaska has reported at least an imported case of Zika virus. So we've all been dealing with this. We've certainly had some cases here at the University of Chicago. There's ongoing Zika activity in Florida. This is the most recent active Zika virus transmission in Florida map from the CDC. You can see there's no place where pregnant women are advised not to travel. But there are a big swath of South Florida that is pregnant women should consider postponing travel to this area. There's also an area of Zika cautionary area in Brownsville, Texas where it's recommended that women consider postponing travel to this part of the world if they are pregnant. And what are the pregnancy outcomes been for us? Well there have been 875 completed pregnancies in the United States where the pregnant woman tested positive for Zika. Of these 36 live born infants had birth defects. They have not come forward to say exactly how many of them have microcephaly or one of the other birth defects that are associated with Zika and there were five pregnancies that were lost with birth defects that were thought to be due to Zika. That is the government's information as of 12, 27, 16. So this is a problem that obstetricians are facing and pediatricians are facing today here and we continue to get calls about this regularly from the obstetricians at the University of Chicago. And the uncertainty about the long term outcomes of these babies is a challenge even when women have access to care and many resources. The CDC's recommendations are to just not travel to areas where people have Zika which is great I guess unless you have family there need to be there for a reason. And they say if travel is needed you should discuss with your healthcare provider first in order to get counseling and advice on mosquito precautions. Women who have traveled to areas where Zika is active should have testing within two weeks even if they have no symptoms because 80% are asymptomatic. And pregnant women should use barrier precautions when having sex with a partner who traveled to an area with Zika for the duration of the pregnancy. And should not attempt getting pregnant again for at least six months after the last known exposure of the male partner and then another eight weeks, whatever, it's long, whatever. For women of reproductive age the recommendations are equally strong that planning of pregnancies is recommended. This may be one of the first times that a public health agency has come out and just flat out said, plan your pregnancies and you should have and we should give people safe and affordable access to birth control methods that meet their needs. Zika testing should be done if you travel and you're symptomatic and you're of childbearing age. For those who travel to areas with Zika who remain asymptomatic, women should wait at least eight weeks after the last known exposure to his tempt conception and one should use condoms when having vaginal anal or oral sex with a man who has traveled to an area where Zika is active for six months after the last known exposure. There's a lot of language describing how if the woman chooses not to, she should be, chooses to have unprotected sex with a man who's traveled. She should have reliable birth control during the entire time and for at least eight weeks after that six month period is over so that she doesn't conceive until then and these dates are made, these recommendations are made with the uncertainty of not really knowing if eight weeks is enough. There's pretty good evidence that eight weeks is enough time to clear the virus and that there's no long-term effects for women who previously had Zika, who become pregnant more than eight weeks after their Zika virus infection but we don't know everything we need to know. This led someone and those recommendations from CDC stem from the World Health Organization led a representative from the World Health Organization to say in the New York Times, it's important to understand that this isn't the World Health Organization saying, hey, everybody, don't get pregnant. It's that they should be advised about this so they themselves can make the final decision. So that brings up the question, is public health statement advice or is it directive? How heavily should it weigh on that scale? Is it like you definitely shouldn't get pregnant no matter what or is it you maybe should think about not getting pregnant and what are the consequences for people who do even though they knew and were advised by their public health agency not to do so? Is there some sort of responsibility? What's the, whose autonomy is this and does it help or hinder the autonomy? These are questions that I don't have great answers to and I think that it's going to be something that happens largely between a woman and her physician but policies and other directives and advice from other bodies to which women and men look to for advice and counseling have been affected. The last year in February the UN special envoy for, let's see, what was he actually? The special high commissioner on human rights urged the abortion banning states in Latin America to allow abortions for women who may have had Zika that it is no longer acceptable according to the UN for them to eschew abortion because they can't provide adequate family planning services. They need to provide this instead in order to protect themselves from all sorts of downstream consequences. Even the Pope suggested that contraceptives could be used but it would be acceptable to use contraceptives if you live in an area with Zika. Some have said that his statement meant that it was the lesser of two evils but it's not clear if the other evil is delivering a child with Zika or having an abortion. We assume he meant abortion but there are some arguments that perhaps the Pope actually means the delivery of a child with Zika that could have been prevented and if the Catholic church can change its mind about its long-term held beliefs about contraception maybe we need to be a little bit more flexible in the way that we make policies going forward. I would argue that the questions that we ask ourselves about whether or not these are directive or advice are important for patients and their doctors but I think it's also important for us to think about these thought experiments of things like Zika and Ebola when we make policies and recommendations about everyday care of pregnant women that we should consider how those hold up in the situation of having issues like Zika and Ebola to deal with. So some obstetricians have written about what they think the duties are of healthcare providers who are counseling patients about Zika and they have said that the most important thing is to talk to patients about travel, to mention, to find out their risk factors and to prevent pregnancy and routes of disease transmission. For those of you who are unaware, DEET and Picardin and IL-3535, all of which are ways of their sort of mosquito repellents are perfectly safe in pregnancy. DEET actually there was a randomized, a double-blinded randomized placebo-controlled trial of using DEET in the second and third trimesters of pregnancy and it was found to be completely safe and there's good evidence in animals that it's safe even in the first trimester. So there's no reason not to use DEET if one is traveling and there are a lot of things that can be done to prevent mosquito-borne illness in patients and people who are traveling to these areas and they absolutely should be, these options should be given to women. For those who don't want to delay pregnancy or who for some reason do not want to delay pregnancy, we need to be respectful of their autonomy. We should offer testing and monitoring and legally permissible ways of termination if that's within their belief system as well and we should support and help women manage that uncertainty that is weighing on their scale. That scale that for us includes our own health when we're taking care of patients with Ebola or the health of other patients or the health of the population at large is weighing that same weight of uncertainty is weighing on these women as they make these decisions about their own child. Before we move on though and I think it's important for us to take a moment to think about these two illnesses as important pieces of what's happening in a global perspective, but there's also another illness that we take care of on a regular basis, HIV, that bears a lot of similarities to these. HIV was once considered to be a disease for which it was a danger for healthcare providers to do any procedures on people with HIV. For a long time there were a lot of surgeons and obstetricians who were worried about taking care of these patients like we have with Ebola. There was also a time when we thought that women who had HIV who had children were essentially, there have been prosecutions of women for delivering a child with HIV or getting pregnant even though they knew that they had HIV sort of echoing the things that we see with Zika and the requirements that people not get pregnant or not travel even though that may be what they really need or want to do for other reasons in their lives. But we have made our way through this by using knowledge and science to help take the weight of some of those uncertainties and fears off the scale. In the beginning without intervention mother to child transmission in the United States was about 20% same in Europe and in the rest of North America. We started using AZT during pregnancy to help reduce the transmission and we started doing C-sections and testing women more aggressively and we found that we could reduce the perinatal transmission to 1% or even less. It's been a very long time since a baby has been born with HIV when the mother knew that they had HIV and had access to care. The clinics that were set up to take care of babies born with perinatal HIV are evaporating as the children grow older and reach adulthood and aren't replaced by new ones. We can early aggressive test in the state of Illinois we now test women with an opt out. In other words, you have to specifically ask to not be tested for HIV if you're pregnant and if you continue to refuse testing for HIV after the delivery of your child will test your baby which will tell us what mother's antibodies were not anything about the baby and that's perfectly allowable in the state of Illinois. Many states have these laws. We do effective antiviral therapy throughout pregnancy. We have elective C-section if the viral load is greater than 1,000 and we recommend formula feeding over breastfeeding in order to help prevent the transmission of HIV and the question has now shifted from how to prevent the mom from giving the baby HIV to how to prevent mom from getting HIV from a partner who may be discordant. And so we've come a long way. We've passed many of the obstacles that are present in Ebola and Zika care but we now are talking about the use of PrEP for discordant couples. That's pre-exposure prophylaxis by taking Truvada every day in order to avoid getting HIV from a partner who's a zero different from you or a zero positive and you're a zero negative. You can also use infertility treatments to help reduce the likelihood of HIV in discordant couples. For example, you can wash the sperm and couple that with in vitro fertilization with intracellular plasmid sperm injection and this has been proven to be highly effective in avoiding seroconversion of uninfected women in HIV discordant couples. And the more we use PrEP to prevent the transmission in discordant couples, the more we're going to see discordant couples who are desiring pregnancy which we have accepted is a totally wonderful thing for patients even those with HIV. And we are happy, it's not an accident, it is a planned pregnancy for these people and now we think how are we going to prevent them from getting HIV but also allow them to get pregnant? There are no reports of HIV infection in laboratory personnel or of cross-contamination of gametes and embryos belonging to other couples and I'll remind you that we handle HIV positive specimens in every laboratory and specimen area of this hospital and in every hospital in the United States without cross-contamination or problems in the past. So there it's been decided and recommended by the Ethics Committee of the American Society for Reproductive Medicine that there's no ethical reason to withhold fertility treatments at clinics with necessary resources to provide care to HIV infected individuals and the necessary resources aren't great, it's a separate freezer. I mean we're not talking about, they're expensive freezers I get it but infertility treatments are not inexpensive and many patients with HIV can't afford them anyway but those that can should have access to them and if a clinic can't provide them then they should find a center that can help serve their needs. Yeah, fewer than 3% of registered U.S. assisted reproduction technology practices provide service to couples in whom one or both partners have HIV. I called 10 centers in the Chicagoland area yesterday to ask if they did reproductive technology for women with HIV or men with HIV where the man has HIV and all of them said they had never done it before. Two said we might be able to do it but we'd have to send your gametes or embryos to another place to store them. Do this, take this step. So I know this is, we still have a little bit of time, I talked faster than I thought but I wanna say in summary that infectious disease in pregnancy there is really a lot of risk to a third party complicates every decision that happens in pregnancy and infectious disease is just up the ante by adding risk to community and sometimes to the healthcare providers themselves. And that void of uncertainty when a new disease comes on the scene or emerges from another part of the world often is easily filled with fear and that fear can weigh even more heavily on our scales where we're determining how much autonomy to afford patients that fear weighs even more than the uncertainty does. When in doubt there's good evidence that we should start with things that are known goods like expanding access to care and support securing additional resources even though we may not know what to tell women who are pregnant and have Zika and decide that they're going to carry their pregnancy to term and take care of this child we can arrange for services and can plan ahead for the babies that will come that may need these services. With emerging infections the situation is always changing but the good news is that we usually know more tomorrow than we did today and so there's always as long as we help people to weight out the uncertainty and to live with the uncertainty we can help them with more information as it comes along and that is all I wanted to say. Thanks Emily. I know you've been giving me grief for asking you to give me this talk but I've been looking forward to it the whole time. Thank you. It's terrific. I will open the floor to questions. I have questions but I will open the floor first. You're gonna have to ask me a question. I will ask you a question. So when ACOG came out with that interesting position about women suspected not confirmed of Ebola exposure and infection the American College of Surgeons do we have any surgeons in here? Yeah. Do you know what the American College of Surgeons said about this? Yeah so about the specific group of patients and they did not say that you should withhold treatment. No they didn't. They said that you should absolutely take care of those patients and obviously use precautions but we should not withhold treatment. So what do you think was the different what made the difference between the two colleges and their recommendations and how were those viewed and dealt with by the infectious disease community? I think fear. I think there was so much going on. There was a lot of heterogeneity. We did a survey of a lot of academic medical centers and medical schools to ask them what they were planning on allowing patients with Ebola what kind of treatments they were planning to withhold from patients that had Ebola in their Ebola treatment centers and what we found was that almost all of they were all it was all over the map. Who was gonna take care of these patients? Who was gonna be trained? What they were gonna do? Could you be intubated? Could you get a CT scan? Some places were offering none of those things to patients and some places were offering all of them and clearly hadn't thought about how they were gonna clean the CT scanner afterwards. I mean there was some place and then there in the middle you had places that were willing to do this but not that and some of it was clearly thought out like because their resources didn't allow them to do X or Y but some places just it seemed like it was really largely based on a fear of well, none of our nephrologists are willing to do the dialysis so we're just not gonna do it. Without a real serious discussion about what our obligations are to patients and what we really should be doing for these patients but thinking about it as though we are in Western Africa and we are not this is a very different setting here and I think that there were a lot of discussions had around a lot of tables and they all came out in different ways and I think that obviously the American College of Surgeons discussion came out completely differently from ACOG's conversation. I think since then there's been a lot of shifting and moving that it has to be that you should be prepared with as much resource and technology and training as possible to be able to provide everything you possibly can and then the right thing to do is to look at the individual circumstance and that does leave it open to one person not wanting to do X this day at U of C we have a system where we have an ethicist and infectious disease and then whatever expert that's not the person who would be doing the procedure that would be a review panel for whatever procedure would need to be just like whatever was at sort of up for discussion in a patient. We also felt very strongly we had an ethics console from the very beginning and felt very strongly that we needed to provide patients that many patients would test negative and we needed to provide them with the care that they would otherwise get that that was our job. I remember in the discussions there was some nuance right? Yeah definitely. I mean there has to be in terms of for example those should there be a potential exposure we're told that if we in terms of childcare for example because we'd have to be quarantined in terms of childcare arrangements and so some of those other factors were taken into consideration in terms of who would be the obstetrician primarily responsible for caring for that. Of course and we felt that we have a big enough community that it was important to allow individuals to volunteer to participate in this situation as opposed to forcing people to do that. Now in a wider outbreak this is a onesies and twosies outbreak right? Like you're not expecting more than a few patients at a time. If you have a wider outbreak a respiratory born illness where everybody's getting sick you have it's different in two ways. One is that your providers are at risk not just at the hospital but also outside the hospital right? Which is one big difference. And the other is you have bazillions more patients and so you have to rely on people differently and the expectation for service would be higher but it would come with the knowledge that that risk exists not just in the hospital but also everywhere. And so you sort of it's a two-way street the risk is higher all the time. But I think yeah we did we worked really closely with obstetrics to make sure and it was always very clear that we know the outcomes for pregnancy are bad like the baby's probably not gonna survive but we're gonna train a bunch of neonatologists anyway because what if one of them does? What are we gonna do? Oh crap the baby's alive? Like that's not a plan. So we needed to have a plan. So we had a plan and we figured we knew the outcomes would be better with Western medicine than they would be in a small hospital with very little resources in Western Africa so we planned for it. But I think there was some, obstetrics really is an incredibly high risk field when it comes to blood-worn pathogens and that I think is reflected in that statement. Yeah that's what I was gonna circle back to say is that the amount of amniotic fluid and the amount of bleeding rates of hemorrhage even in this country are quite high so I do think that that probably affected some of the difference. But we also learned that in this outbreak that Ebola had a lot less bleeding than everybody expected it to despite its name as a hemorrhagic fever virus. It just didn't result in as much DIC as was expected. The patients had so much insensible losses from GI illness that they were dehydrated and malnourished and they had electrolyte disturbances. They weren't necessarily bleeding out all over the place which changed things. And I think the American College of Surgeons came out with their statement a little later and every week made a difference so yes. Thank you, Gene. Thank you very much for that talk. I was struck by your illustration of how tenuous are some of our ostensibly deeply held moral sort of ethical views are to circumstance. And so I like your idea that these infectious disease reproductive ethics cases serve as a launch pad for thought experimentation. And I was also struck as a resident at the time of the Ebola outbreak at just how incredible the response was both in terms of resources and organization. So the thought experiment I wanted to propose see what you think would be what? Hypothetically, what do you think that we would react differently with regard to reproductive access if you could control Ebola through planned family planning? I mean, if you could control Ebola through the distribution of contraception, do you think that Ebola would have triggered a more widespread acceptance of contraception and abortion? Or do you think it would have also fallen under the penumbra of our sort of distaste for that intervention? And why would Ebola be different than what makes Ebola different? I think that this is sort of the same as when we talk sometimes about how devastating it is to be the physician taking care of the patient who's refusing a life, like a totally life-saving treatment and they really don't want it and you don't feel like they really get it but they're competent to the best of your understanding and that sort of unbelievable stress that you feel in that situation. I think that's how people feel when they're taking care of patients with Ebola and I think that if you could prevent it with something as simple as contraception that almost no one would be against doing that. I think you'd probably find some people who would be against it because there's gonna be a range of opinions everywhere but I think you would find that the process of watching people die in a miserable, horrible fashion is very, very persuasive. So interesting though, because what is the threshold at which concerns about sequela from infectious disease that could potentially be prevented through family planning or secondarily managed through abortion? What is the threshold at which this country will say, you know what, this is something that we really should be talking more about. There was a lot of discussion and there continues to be discussion around contraceptive access and abortion access both in the United States and in Latin America around Zika but I will say and who knows what the future holds but inherent in this discussion about the future of the Affordable Care Act is a discussion of dismantling women's guaranteed access to contraception through the Affordable Care Act. Similarly, abortion bans are continuing to happen in this country. Specifically, there are a few outliers or like a six week ban on abortion which have not held up so far but the week at which most of these cutoffs are happening in terms of abortion bans are 20 weeks and when we're talking about monitoring for microcephaly. We can't tell until after. Right, that's around when we can start making these diagnoses so I don't know what it takes to shift that view or the kind of the national will to recognize that this is something that is important for women and men in terms of transmission of disease but Zika clearly is not enough and that I think is kind of a, I don't know what the point is. I think there's something really important to say about the fact that you have these like really sort of long term entrenched abortion and contraception bans in countries now really being rediscussed. I mean these are places of the world where I didn't think we were ever gonna really talk about those things and they're being discussed. They're being like encouraged by the UN counts high commissioner for human rights and I didn't know we had that but it's interesting and you know they're being discussed by the pope. Like the fact that you see these people I think we're getting, like we're figuring out where the line isn't. The gray area between the two is becoming smaller, right? We're seeing where we can walk up to that and we're learning something. Maybe we may not be quite there yet. And I think part of that is because we don't know what the outcomes are really gonna be like for these kids and it's really like the small villages in Northern Brazil where they're seeing so many of them are really far away from here. Like I mean it takes along not just by a plane but like they're really different from here and we don't have moms bringing in microcephalic babies to the clinic to sit next to the other moms. We don't have them like at the grocery store and so it sort of has to be a thing. I think. I had a few questions. One being we talk about the recommendations that women not travel with Zika and I was wondering if there was any more specificity that's come out of epidemiological information in terms of when during pregnancy exposure matters. And as a second question you talked about some of the cases of Zika in the US and how it's affected such a wide spot of the country. I was wondering if there were any data on women having an abortion as a result of contracting Zika and being aware of that during pregnancy. And then my third and final question is with Ebola you talked about the pre-test probability being so low in this country and being able to utilize that information in terms of the ethics of what we provide to rule out type patients. But since that's not a static number how do you do that in real time? Okay, starting from the top. There's very specific information about exactly where you can and cannot travel. The CDC website has, and it changes all the time and they say on the bottom of the page when it was last updated. The other part of that question was about, oh yeah, many women have had abortions because they've been exposed to Zika and they're pregnant and they don't want to carry the pregnancy through. But I don't know what more to say besides the fact that absolutely women are being counseled that that's an option for them and that if it's available to them, people are doing it. And the thing is in terms of abortion reporting so there are some requirements in terms of reporting abortions but the indication for abortion is not something that we necessarily ask or certainly not mandated in terms of reporting. So I think those numbers are probably more anecdotal than anything. And I think you had more questions about the locations and I can't remember exactly what you were asking. I wasn't asking about the locations. My first and my third question were, does it matter when during your pregnancy you can drag Zika first trimester, second trimester, third trimester? It's expected that the first trimester is worse. That's all we know. Okay, and then the third question was in terms of the pre-test probability. That changes, but when you're in the middle of a situation like Ebola, there's outstanding information coming into you all the time. It may not be available to you but the team of people that are running whatever Ebola outbreak thing, when we had patients here that we were ruling out for Ebola, we had phone conferences with the CDC response team like four times a day. And so they're giving us the most updated information about exactly what's happening here, how many patients they're currently testing where and what and we get lots of information down to the neighborhood where the people lived in Liberia if that was a place where there was a lot of cases or not a lot of cases. So we work with the public health departments when it's a onesies and twosies, we can get that kind of information. When it's a massive outbreak, it's a lot less granular, right? But you get something, you just, there's constant information, like public health works really hard to give us as much information as they can given the situation. We don't, I feel like they've been a big partner in all of this. Thanks. Hi, I was just wondering, so with the shifting cultural tide in the US, we talk a lot about the sort of construct of Western medicine as sort of a pinnacle and what we're striving to get other countries to be on par with our sort of rigidity in terms of the hospital system and understanding. And I guess my question is, do you feel like we're on the brink of a big change as reproductive medicine becomes more restricted in the US and more available in countries where we once thought it wasn't ever gonna be available? I think that's a big question. Like, are you, from an ethics standpoint, do I think that we're gonna be, we're gonna lead the way in a lot of things and we're not gonna lead the way in other things. There are certainly things, I mean we're not, we don't have universal healthcare and there are other countries that are leading the way in a more socially just way of providing medical, in my opinion, a socially just way of providing medical care. So I don't know that it's gonna sort of be a sea change necessarily but I'm supportive of, I think that we need to pay more attention to justice. I mean, I think we both agree about that. There are a lot of us who agree about that but the more you do like this epidemiologic ethics side of things and you think about justice more instead of attempting to not ever think about justice, you want more of it and it becomes more apparent when it's not there. I was wondering if the gentleman in front of you had a question first, thank you. Just want to be just. I have a question about the numbers which actually tie into the probabilities of things going wrong, this is a cratic method. Okay, so with AIDS you've got your risk to the fetus down to 1% but with this virus. Zika. Yeah, the Analsineurology paper last month said that 36% of the fetuses that they ultrasounded had microcephaly, which to me means 100% abnormal. Okay, so I don't think we can say that it's controllable if you're pregnant, first of all. And then you get to the next question here about the autonomy and it sounds good to let people make their decisions. Okay, sounds good. But in medicine we have other rules. You know, like if a person is dangerous to themself or others, the whole thing with the Jehovah's Witnesses and the children with medical interventions, et cetera. Where do you draw the line here? Okay. I want to say that I, no these are great questions. So if to a couple where both are heterogeneous for a genetically recessive disease like say cystic fibrosis or whatever, we don't put any requirement on them to not conceive. One would probably consider that to be on the border of eugenics. We also don't require them to have pre-implantation genetic testing nor do we pay for it. We don't require them to have IVF or pay for them to have IVF with pre-implantation genetic testing. And we allow a 25% likelihood that their baby will have a significant illness that may result in, it will probably result in a lifetime of a lot of medical care, a lot of cost and may end up in a premature death. And that is perfectly allowable by us. And so the likelihood, we also don't, while we do think that, most people now think that most babies born to women who had Zika, especially early in the pregnancy will result in some abnormality. But we don't know how severe that abnormality is gonna be in terms of their life yet because of these babies haven't grown up. And so while severe microcephaly with a crushed skull is probably not gonna have a great long-term outcome, we don't know about the babies that don't have problems and that look okay but have like a mild intellectual disability. So I think you have to be careful that you don't wanna cross into eugenics. There's like this huge valley of grayness between autonomy and eugenics and we're somewhere in here. I'm not talking about eugenics, which is a different conversation. I'm talking about deliberately having a baby that's going to be abnormal. What do you mean deliberately? What is the alternative? I guess my question is what is the alternative and how does that? So let's say you're in a state that doesn't allow abortions. Okay, we do have the experiment going on in the United States. That's not what Donald Trump might do. Okay. Keep going. Right, so you're saying, well, they might just be mildly retarded. That's okay, all right? Is that your argument? What is the alternative mandating abortion for anomalous fetus? Right, I'm not saying that's the alternative but I'm saying that you're arguing that it's a good thing to do. I think that we're probably on the same page and arguing that it's up to the individual to decide what is best for her and her family. And I'm raising the question, is that a valid position? I think that part of the problem here is that, and this was echoed in an opinion piece that was written in the Journal of Bioethics and Developing Countries. And it was an opinion piece where the authors suggested when we only focus on the children, like the outcome of the child, we fail to recognize all of the good things that we can do for the women before this. These are parts of the world where women don't have adequate resources for all of these things. We can do a lot to prevent that question from ever coming up. And so we should, it's incumbent upon us to prevent that question from being asked by doing the right thing from the beginning. And what the right thing is, I'm not sure. And I think that, I mean, everyone who's been to an ethics conference with me knows that I think there are limits to patients' autonomy. But I think that there's, but I think, I mean, you make a very provocative point. And that's what we do here. This is ethics, we make provocative points. Yeah, that's why I'm doing it. But I'm saying that with Zika, it isn't a black, I mean, it's not a shades of gray situation. I mean, this is a very dangerous virus if you're pregnant. It is a very dangerous virus if you're pregnant. But I would argue that we don't know and that there is value to human, we've already decided as a society that there is value to every human being. I am not making a statement about the moral status of the fetus. I am making a statement about moral status of humans that have been born right now. And I'm not making it, whatever, you get it. I'm not going there. But this is, it's so messy to me. I just can't handle it. Keep going, keep going. So I think we've decided that there's value to everyone that's born. And so, it's hard to decide. Your question is the question of the moral status of the fetus. And I also think, I'm not answering it. Right, but further, at a very practical level, performing an abortion on a woman who doesn't want an abortion. Like, how does that happen? You're never gonna find a provider who's gonna do that. Yeah. You know, so to a very, like, there's the kind of ethical- Well, you might, but not here. Yeah, well, yeah. There's an ethical and philosophical question. And then there's also the very practical. Like, I just- The practical is your friend in these difficult situations because you can't escape the practical. And it sometimes negates dealing with the thorny issue. And sometimes you need to, like, escape the thorny issue by just dealing with the practicality. You just have to acknowledge that there's a thorny issue you're not dealing with. Yeah. So I was wondering to what extent Zika will be like a trigger that shifts attitudes more generally. Like, for example, the women who got abortions because of Zika. How many of them were, like, anti-abortion or pro-life or whatever before that? There's no data about that. Right, and I will tell you- I would love to know. How many women who come for an abortion for a fetal anomaly or sexual assault were anti-abortion before they were in that situation? You would know better than I would. Right, and I mean, I'll tell you, it's not uncommon to hear someone say, I don't believe in this, but here I am. It doesn't always necessarily even shift their opinion after the procedure for other women. I think that this, you don't know how you're gonna feel until you're in that situation, and oftentimes when women are in that situation, they are understandably thinking about themselves and not necessarily thinking about the political context of their- A personal justification that they do not extrapolate the meaning to others. But they might. They might, absolutely. And I wonder, now that the Pope has said it's okay to use contraception for Zika, maybe women have started using contraception for Zika and how many of them will continue? Yeah, 99% of Catholic women have used contraception in their lifetime. So, I don't, pardon? In the United States. In the United States. But yes, you're right. I think that it is absolutely an opportunity to have people consider things that they may not have otherwise considered, absolutely. Any other GZ questions? Emily, did you have a question? I'm sitting back here with a bunch of neonatologists. But it's hard to see these outbreak situations and not think of the role that the media plays in all of this, and we're sitting here saying, what's the difference between Zika virus and CMV and the outcomes in the fetus, and it's essentially nothing. So, I wonder how you feel or what you think as far as how the outbreak component is, yes, it's an infection, but truly it's a media frenzy outbreak situation and how that should play a role in determining how people deal with their pregnancies. Because I think most people, when they think of Zika, they think of the child with the itty-bitty head. They don't think of the 80% of people who don't have any effect of it on it. CMV, I think one of the biggest differences is that only 10 to 15% of the population in the United States is susceptible to CMV by the time they're women of childbearing age, whereas 100% of us are susceptible to Zika. And I think that the media plays on that and adds fear. And we have to be, this is, when I say all this stuff about fear, fear weighs, really, it weighs a lot more than uncertainty when you think about it and balancing risks and benefits. When you're just talking to a patient about this one little thing that they need, the fear oftentimes weighs more than the benefit even if the benefit is life and there's like the risk is like a toenail, hangnail. And so we know how heavy fear is. And so the media can do fear, but we also need the media to do education and to help people to see. We can't change our views unless women are on TV talking about how they think it's, or people are on TV talking about how they think it's okay to do things like use contraception to prevent Zika, your pregnancy during a time when they're at risk for Zika. And so I think that's, we need, it's a double edged, well it's a, I mean it's a, really it's a sword that can also be helpful. It can help and not hurt, and hurt. And CMV, we also have more longitudinal data, correct? To no outcome, you know, kind of. Oh yeah, yeah. It's still a moving target, right? We don't have much. The uncertainty fills this, it gets filled with fear. Yeah. Yeah, the more we know, the more we will do. One practical kind of FYI type question, not ethical. A young couple, male is positive for Zika, female is not. Is she at risk in her fetus for lifelong? No, she's, she can get Zika from that partner. She should, the recommendation is she should avoid getting pregnant. She should use barrier precautions. And if she's not going to use barrier precautions, she should use a reliable form of birth control until six months after the, the male's last known risk factor because Zika can last in semen for up to six months because you don't want her to get Zika. She can go ahead and decide to not, not use a barrier method, get Zika. If she is able to zero convert to Zika, then she can get pregnant eight weeks after that. So once the male semen is, is clear, then they're okay? Yeah, so the understanding right now is that there's no long-term issues. And that like, that once you, that it's a direct viral effect from being viremic during pregnancy. And so it is not thought to be an immunologic phenomenon that happens later on. And so that we know because there does not appear to be additional risk for the women who had Zika back during these other outbreaks. It's a limited supply of people and there haven't been a ton of testing done, but there is not a lot of evidence that there are ongoing problems in the future. We think eight weeks is good enough. Once the virus is gone, then mom should be okay. And so some people say, just go get, go get Zika now and then get pregnant. And immunization would be great, but there's a whole, like whole another thing about how we test vaccines. We never test them on pregnant women. We never use them in pregnant women. This is mostly would be needed for pregnant women. And so how are you going to prove its effectiveness if you're never gonna test pregnant women or even women of childbearing age because they might get, have a bad reaction and get pregnant. And so this is, there is a lot of, you can look up Zika vaccine pregnancy and you can see tons of little editorials about how we need to change the way we do vaccines because we're totally, we're hamstrung. The current methods we use to test vaccines, we are completely hamstrung for fixing the Zika problem. Thank you, Emily. This has been very interesting. My question has to do with the justice perspective and that is given the outbreak and anticipation of more children with the effects of Zika virus, have governments appropriated funding for services for these children? And are there advocates out there for them doing so? And I would also comment that I think we have to be careful from an ethics perspective, talking about intellectual disability as a harm in and of itself and maybe kind of look into the underlying assumptions with a diagnosis of microencephaly and intellectual disability and what our biases may be about that. And when we talk about it, I think we all have some sort of understanding about it but I think we need to be careful about the why and when we use the quick buzz words, but I think what do we mean by what is wrong with an intellectual disability if something or what is the harm? Yeah, that's a sticky situation. I know it's a two-part. It's not really a part. I don't wanna get too into the weeds on that aspect of things but the first part that you're asking about is the funding. The most of the countries in South America where there's a lot of Zika do not have good healthcare systems and so they have almost no plan for how they're gonna take care of the Zika babies. No. Do you know if the United States has any funding? Well, it took us how many months to fund mosquito prevention in areas where we have 80s Egypti? Our Congress went home for the summer without appropriating a bill to help get rid. I mean, we can kill mosquitoes here. We're pretty good at that. Like it's not rocket science and yet they all went home for the summer without appropriating funding for that so I'm gonna go with no and I don't think it's on the first 100 days plan. I don't know. Are the Russians doing it? Maybe that might help. Oh my God. That was evil. Right. And with that, we'll call this close. Yeah, thanks.