Running head: THE ZIKA VIRUS IN BRAZIL 1

Health Impact Framework/Research Paper

The Zika Virus in Brazil

Delaware Technical Community College

NUR 310 Global Health

Miranda Jennings

May 7, 2017
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Abstract

The World Health Organization declared the Zika virus an international health emergency

following an upsurge in microcephalic infants in Brazil in 2016 that were linked to the virus

(Carlson, Doughtery, & Getz, 2016, p. 2). The Zika virus has been around since 1947, but has

recently reached the Americas (Centers for Disease Control and Prevention [CDC], 2017). The

virus does not cause many lasting effects to healthy adults but has devastating effects in fetuses

when pregnant women are infected with the virus (CDC, 2017). The five-tier health impact

pyramid describes how different types of public health interventions can have a lasting impact to

improve public health (Frieden, 2010, p. 590). By applying the five tiers of the health impact

pyramid to the Zika virus and its transmission, it is obvious that many more steps need to be

taken before there are lasting impacts on the disease and improvement to public health in the

Americas. Through continued education and scientific advances toward a vaccine, a slowing of

disease transmission and eventually complete Zika virus eradication is possible.

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Health Impact Framework/Research Paper

The Zika Virus in Brazil

Introduction

The Zika virus was recently declared an international health emergency by the World

Health Organization following a twenty-fold upsurge in microcephalic infants born in Brazil that

were linked to the virus (Carlson, Doughtery, & Getz, 2016, p. 2). The Zika virus was first

discovered in 1947 and is named after an outbreak that occurred in the Zika forest in Uganda

(Centers for Disease Control and Prevention, 2017). The virus typically presents as a mild

infection including fever, rash, joint pain, and red eyes (CDC, 2017). The major long term effects

of the Zika virus are seen when the virus infects pregnant women. The Zika infection, when

encountered during pregnancy, can cause a birth defect called microcephaly (CDC, 2017).

Microcephaly translates to small head (Sinay, 2016, p.5). When babies are born with

microcephaly, their brain is not able to develop properly (CDC, 2017). The condition is linked to

several issues including seizures, developmental delay, intellectual disability, balance issues,

hearing loss, visual impairment, and difficulty swallowing (Sinay, 2016, p.5). There is currently

no vaccine to treat the Zika virus.

Discussion

The virus primarily spreads via mosquito bites of an infected Aedes species mosquito, but

can also be spread through sexual intercourse and from a mother to her fetus during pregnancy

(CDC, 2017). The Aedes species of mosquitos also spread other diseases including dengue fever

and the chikungunya virus (Rasanathan, MacCarthy, Diniz, and Gruskin, 2017, p. 526). The

mosquitos become infected when they bite a person who is already infected with the virus, then

spread the virus to other people when they feed on them (Rasanathan, et al., 2017, p. 525). The
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Zika virus is passed through sex from a person who is infected with the virus to his or her partner

even when they are not showing any symptoms at the time (Rasanathan, et al., 2017, p. 526).

Pregnant women who are infected with the Zika virus can pass the virus to their fetus, leading to

serious birth defects or even miscarriage depending on when they contract the virus in their

pregnancy (Rasanathan, et al., 2017, p. 525). The last way the virus can spread is through blood

transfusions. Prior to the widespread news of the Zika outbreak, there were several reported

cases of the virus being passed through blood transfusions in Brazil (CDC, 2017). The Centers

for Disease Control and Prevention (CDC) is now reporting that once a person has been infected

with the Zika virus, they will develop an immunity to contracting the virus again (CDC, 2017).

One of the reasons the virus is spreading at such a rapid rate in Brazil and throughout the

Americas is that there is no pre-existing immunity to the virus (Rasanathan, et al., 2017, p. 526).

Of the areas in Brazil, the poverty-stricken areas were especially hard hit with the Zika virus.

First Tier

Socioeconomic factors that affect health are the bottom tier of the Health Impact Pyramid

(Frieden, 2010, p. 591). Socioeconomic factors that affect the incidence of Zika transmission is

people that live in poverty. Areas of poverty have a higher incidence of Zika virus transmission

for two reasons: they provide an opportune breeding ground for the Aedes mosquitos and

education on safe sex practices and disease transmission is lacking in those areas. The Aedes

mosquitos are strongly associated with poverty-stricken areas because they breed in overcrowded

areas with poor sanitation (Rasanathan, et al, 2017, p. 527). In overcrowded areas, mosquitos are

able to infect a larger number of hosts, which increases the incidence of Zika disease

transmission. Mosquitos breed in still water, so areas with poor sanitation and garbage dumping

are ideal for the Aedes mosquito breeding (Rasanathan, et al, 2017, p. 526). Areas that do not
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have clean running water, and rely on wells and rain run off systems, are also at risk for mosquito

breeding grounds and increased risk of the Zika virus (CDC, 2017). Another reason areas of

poverty see a high incidence of Zika transmission is that fewer people can afford proper mesh

screens and mosquito netting (Rasanathan, et al, 2017, p. 526). Poverty-stricken areas of Brazil

are especially hard hit with Zika virus transmission because they also lack proper sexual

education.

The Brazilian culture has specific health beliefs regarding sex and contraception that

contradict current scientific guidelines, which could explain the increase in Zika transmission in

Brazil. According to an article by de Bessa, routine gynecological visits and the use of

contraception is not common among women in Brazil until after the birth of their first child

(2005, p. 436). Furthermore, the culture sees the function of marriage as procreation, so

marriages are solidified as a nuptial union after the birth of their first child (de Bessa, 2005, p.

436). When birth control is used in low-income areas of Brazil, it is often used incorrectly. This

is because women do not need a prescription or a gynecological visit to acquire birth control.

Birth control is available in Brazilian pharmacies over the counter for all women without a

prescription (de Bessa, 2005, p. 437). Since women do not need to see a doctor to obtain birth

control, they often choose a pill brand based on the advice from their friends (de Bessa, 2005, p.

437). When birth control pills are used, they are often used incorrectly in Brazil because the

Brazilian culture associates menstruation with fecundity or fertility (de Bessa, 2005, p. 440). For

this reason, Brazilian women often believe that you can only become pregnant five days before

and five days after the onset of your menstrual period (de Bessa, 2005, p. 440). Since women

believe you can only get pregnant just before and just after your menstrual period, they often

only use birth control pills at those times (de Bessa, 2005, p. 441). According to medical science,
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the time of ovulation is actually three days before and three days after the fourteenth day of the

menstrual cycle (de Bessa, 2005, p. 440). To decrease the transmission of the Zika virus, proper

sexual education and use of birth control needs to be provided to the people of Brazil.

Second Tier

The second tier of the Health Impact Pyramid is changing the context to make

individuals default decision healthy (Frieden, 2010, p. 591). These interventions are ones that

make the healthy choice the default one regardless of citizens education, income, government

provision, and societal factors (Frieden, 2010, p. 591). An intervention that would help to control

the spread of the Zika virus in Brazil would be aerial spraying as a form of mosquito control.

Aerial spraying has been performed in areas of the United States including Miami, Florida;

Tampa, Florida; and New Orleans, Louisiana (CDC, 2017). Aerial spraying is when insecticides

are sprayed from airplanes to treat very large areas quickly and efficiently (CDC, 2017). The

insecticide often used in aerial spraying is called Naled, which is safe for humans, animals,

plants, and the environment and will not pollute the water supply when used in small

concentrations (CDC, 2017).

Third Tier

The third tier of the Health Impact Pyramid is long-lasting protective interventions

(Frieden, 2010, p. 592). Long-lasting protective interventions for the Zika virus include

vaccination and immunity. On August 3, 2016, the National Institutes of Health (NIH) launched

a clinical trial for a Zika vaccine in response to the Zika outbreak in the United States (American

Hospital Association [AHA], 2016, p. 1). The clinical trial included 80 volunteers who were

injected with the developed vaccine (AHA, 2016, p. 1). The clinical trial has not yet finished, so

at this time there is no vaccine available to the American or Brazilian citizens. The CDC has
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determined that people who have been infected with the Zika virus are immune from reinfection,

which is good news for women who have tested Zika positive that want to conceive in the future

(CDC, 2017).

Fourth Tier

The fourth tier of the Health Impact Pyramid is clinical interventions (Frieden, 2010, p.

592). The clinical interventions for people infected with the Zika virus are to treat the symptoms

of the disease because at this time there is no specific medication or vaccine available (CDC,

2017). The symptoms for people infected with the Zika virus are fever, rash, headache, joint

pain, conjunctivitis, and muscle pain (CDC, 2017). These symptoms typically last from several

days to a week and often are not severe enough for people to go to the hospital for treatment

(CDC, 2017). Several tests have been developed for the Zika virus. The United States Food and

Drug Administration (FDA) has approved two diagnostic tools for the Zika virus that include the

Trioplex Real-Time RT-PCR (rRT-PCR) assay and the Zika MAC-ELISA (CDC, 2017). Both are

blood tests and the Zika MAC-ELISA can also be performed on cerebrospinal fluid to detect the

presence of the Zika virus (CDC, 2017). Once someone has tested positive for the Zika virus, the

CDC recommends they get plenty of rest, drink a lot of fluids, and take medications such as

acetaminophen or ibuprofen to reduce fever and pain (CDC, 2017).

Fifth Tier

The fifth and final tier of the Health Impact Pyramid is counseling and educational

interventions (Frieden, 2010, p. 592). To decrease the incidence of Zika transmission in Brazil,

proper education needs to be provided to the Brazilian people to change their individual views of

the virus and to help them to make healthy decisions. The Brazilian people need to be educated

on how to prevent mosquito bites, how to decrease the incidence of mosquito breeding, and how
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to practice safe sex to avoid passing the Zika virus to their partners. The role of the nurse would

be to provide this education to all of their patients. To avoid mosquito bites, the CDC

recommends wearing insect repellent and wearing clothing with long-sleeves and long pants

(CDC, 2017). The CDC also recommends using screens on windows and doors in homes and

using air conditioning whenever possible (CDC, 2017). When air condition is not available, such

as in areas of poverty, people are to use mosquito bed netting to avoid mosquito bites (CDC,

2017). To prevent mosquito breeding, the CDC recommends emptying and cleaning all items

outside that hold water once a week (CDC, 2017). The best way to spread information about

these ways to prevent mosquito bites and to decrease the incidence of mosquito breeding is

through mass media. In poor areas of Brazil this can be done over the radio (Skolnik, 2016, p.

154). In areas that have access to television programs, this can be done either as commercials or

as entertainment education through soap operas (Skolnik, 2016, p. 154). On the soap operas

characters can model healthy behaviors and pass on the important messages regarding Zika virus

prevention (Skolnik, 2016, p. 154). As far as sexual education, the nurses would need to teach

their patients that the Zika virus is spread through sexual intercourse and the proper

contraceptive options to avoid transmission.

With the ineffective birth control use and rising incidence of the Zika virus in Brazil, the

Diffusion of Innovations Model could bring about necessary change in sexual health practices

and in turn decrease the rate of Zika transmission. The first stage of the Diffusion of Innovations

Model is to identify a problem, which in Brazil would be birth control education (Skolnik, 2016,

p. 153). The second step of the diffusion is to use research to address the specific problem, which

would be proper use of birth control pills and other methods of contraception (Skolnik, 2016, p.

153). The third step of diffusion is development of strategies that put the innovative concept into
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a form that will meet the needs of the target population (Skolnik, 2016, p. 153). This would be to

properly educate nurses in Brazil on the use of contraceptive methods and to supply them with

condoms, birth control pills, and other forms of contraception for the nurses to educate the

Brazilian population. To educate the Brazilian population on safe sex, it would also be beneficial

for pharmacists to take the time to educate women on the proper use of birth control pills when

they are buying them over the counter. The fourth step of the diffusion of innovation is

commercialization of the innovation, which would be accomplished via media including radio

and television as well as word of mouth (Skolnik, 2016, p. 153). The fifth and sixth steps of the

Diffusion of Innovation Model involve diffusion and adoption of the innovation and evaluating

the consequences associated with the adoption of the innovation, which would occur after the

correct information reached the Brazilian people (Skolnik, 2016, p. 153). Once the Brazilian

people are able to put safe sexual practices and mosquito prevention into their routine, the

incidence of Zika virus transmission will decrease.

Conclusion

The Zika virus is a new occurrence in the Americas however is it not a new disease and

has been documented since 1947 (CDC, 2017). The virus has few lasting effects on healthy

adults, but has devastating effects on babies when pregnant women are infected with the virus.

By using the multiple tiers of the health impact pyramid to spread education of prevention of the

Zika virus and prevent the transmission of the virus via mosquitos, transmission of the virus will

decrease and eventually be eliminated. Many steps still need to occur to be able to actually see an

end to the transmission of the virus, but scientists are working on the development of a vaccine

and as more countries provide education to their citizens on prevention of Zika transmission and
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use aerial spraying of pesticides, the spread of the Zika virus will decrease and eventually stop

entirely.
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