Background

As the geographical distribution of the Zika virus infection steadily increases, so have the number of cases of
congenital anomalies like severe microcephaly, brain anomalies, abnormal ocular findings, and neurological
impairments that are strongly associated with maternal Zika infection. In 2015, 2.1 per 10,000 live births had
microcephaly and in 2016, 9.61. Conducting screenings on pregnant women for Zika virus exposure is
imperative to determine a causality between the infection and birth defects.
There is a vast amount of studies that have collected data suggesting that maternal Zika infection is the
cause of infant congenital anomalies; however, little surveillance has been done on pregnant women with
asymptomatic Zika infection since the majority of surveillance methods testing for Zika are based on clinical
symptoms and those who do not have symptoms are predicted to be less likely to seek testing. As a result,
the actual prevalence of Zika infection in pregnant asymptomatic women is unknown and most likely
underestimated, making it more difficult for researchers to establish it as the cause of birth anomalies.

Specific Aims and Hypothesis

Compare the incidence of birth anomalies in infants born to a mother with symptomatic Zika infection to
infants born to a mother with asymptomatic Zika infection in order to establish a causal relationship between
maternal Zika infection during pregnancy and congenital defects.
The risk of birth anomalies between infants born to pregnant women with symptomatic Zika infection and
infants born to pregnant women with asymptomatic Zika infection is similar; however, because symptomatic
Zika infection is more easily tested for, cases with asymptomatic infection go unrecognized but are still just as
likely to result in a birth defect.
Study Population
Symptomatic and asymptomatic pregnant women with potential recent Zika infection. Eligibility criteria are
that either the mother, their infant, and/or the placenta tests positive on a laboratory test (RNA NAT, blood,
amniotic fluid, plasma, or urine)1.
Study Design and Procedures
This will be conducted as a prospective cohort study to determine the incidence of birth anomalies in infants
born to asymptomatic Zika infected mothers and anomalies in those born to symptomatic infected mothers.
New data on asymptomatic infected pregnant women will allow for a more accurate overall prevalence of
Zika infection in pregnant women. This data will include the gestational timing of the Zika infection in
asymptomatic pregnant women based on the self-reported trimester they were in when they were exposed to
the virus (either traveling or sexual contact); and for symptomatic infected pregnant women, when they self-
reported the onset of their symptoms. Data will be conducted by a trained medical professional or a study
coordinator such as an epidemiologist.
Definition and Measurement of Key Variables
Exposure of interest is the presence of symptoms in Zika infected pregnant women. Cases who meet the
eligibility criteria will be divided between symptomatic infected and asymptomatic infected groups.
The primary outcome of interest is an infant birth anomaly believed to be associated with the Zika virus
(congenital microcephaly, abnormal brain development, ocular defects, etc.)
A potential confounder in this analytic study may include the presence of another unspecified flavivirus
during the time of testing for Zika infection that could result in a false positive, leading to a higher number of
women believed to be infected with Zika than true.

Analysis
Using the incidence rates for birth anomalies in the symptomatic and asymptomatic groups, a risk ratio will be
calculated to determine if having the symptoms associated with the infection during pregnancy increases the
probability of an infant birth anomaly.
Discussion
One key methodological limitation of this study includes the potential for recall bias in the self-reported data
on time of the onset of symptoms in symptomatic women and time of exposure to the virus in asymptomatic
women. Another limitation of this study is the high cost associated with conducting large cohort studies. In
this case, a big sample size is needed to establish a causal relationship.
One methodological strength of this prospective cohort study is the ability to establish temporality between
gestational time of infection and the probability of a birth defect if a researcher wanted to. Another strength
would be that the results can be highly generalizable if it were to include a large, diverse sample of cases
based on factors like geographic location, race, etc. and if the potential confounding factors and biases are
adjusted for.
Work Cited
1. "Testing Pregnant Women." Centers for Disease Control and Prevention, U.S. Department of Health and
Human Services, 23 Nov. 2016. Accessed 13 Feb. 2017.