Noni MacDonald summarizes the all too familiar ethical challenges surrounding the recent outbreak of Zika virus.

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Zika virus disease is exploding across the Americas and some researchers predict that the mosquito-borne virus will infect approximately 3 to 4 million people in 2016. On February 1^st the World Health Organization declared the recent outbreak of Zika virus and its suspected link to birth defects a “public health emergency of international concern”.

Zika virus was first recognized in the 1950s in a narrow equatorial area in Africa and Asia. Mosquitos, the same ones that transmit dengue and chikungunya viruses, transmit the Zika virus. In May 2015, the Pan American Health Organization (PAHO) issued an alert regarding the first confirmed Zika virus infection in Brazil. Since then the spread across the region has been astoundingly quick, with reports from more than 20 countries across the Americas.

While Zika virus disease is usually mild and self-limited with fever, rash, joint pain and conjunctivitis lasting from several days to a week, it can cause serious complications including Guillain-Barre Syndrome (progressive symmetrical paralysis and loss of reflexes starting in the legs). Zika virus disease can also cause significant problems for pregnant women including stillbirths as well as birth defects. Children are born with abnormally small heads and brain damage – a condition known as microcephaly. The potential risks to pregnant women are such that the Centers for Disease Control and Prevention (CDC) in the United States and the Public Health Agency of Canada now recommend that women who are pregnant (in any trimester) consider postponing travel to any area where Zika virus transmission is ongoing. CDC has also developed management guidelines for health care providers caring for pregnant women who may have contracted Zika virus while travelling.

The Zika virus outbreak raises a number of ethical issues.

First, there are concerns related to Zika research. At present, there are no known specific treatments and no vaccine to prevent Zika infection. Several companies are now working on developing potential vaccines for Zika virus. If and when a drug or vaccine reaches the testing phase, should pregnant women be included in the research? What priority should be given to the development of a drug or vaccine, given other major viral diseases without vaccines – for example, chikungunya virus or enterovirus? On January 26^th, the U.S. government announced research into a possible vaccine for Zika virus.

Second, there are concerns related to travel. Should pregnant women who have booked holidays to affected countries be given a complete refund? Who should pay for any losses? Should all travel agents be required to alert potential customers of the risks for pregnant women? This is a fast moving outbreak; whose responsibility is it to stay up-to-date with affected countries once a ticket has been purchased? As of last week, some airlines started offering refunds to passengers with flights to countries in central and South America.

Third, there are concerns related to care for those affected by Zika virus. Zika symptoms may initially be confused with those of dengue and chikungunya infections. For pregnant women, CDC has recommended both serological as well as amniotic fluid testing, followed by serial ultrasound testing if the prior tests are positive for Zika. Since there is no treatment for Zika and microcephaly in the fetus is irreversible – what counseling and advice should be given to the pregnant women who test positive? The CDC guidelines offer some answers. However, some parents whose children were born with microcephaly that is believed to be caused by Zika, argue that the government is not helping them. Health officials in Brazil have already acknowledged that their health care system isn’t currently equipped to provide adequate care and support for families affected by Zika either in the short or longer term. Those affected will have a lifetime of needs.

Fourth, there are ethical questions related to prevention. Prevention is important, but the current recommended strategies centre on personal prevention of mosquito bites (clothing, repellant etc) and environmental prevention with vector control (no standing water near homes, screens etc). Neither of these strategies are very feasible, however, on the grand scale needed to prevent Zika transmission in affected countries. Yet, that advice and the recommendation to avoid pregnancy are what governments in the affected countries propose. Avoiding pregnancy is easier said than done. However, birth control may not be readily available, affordable, or culturally acceptable. How should this birth control problem be addressed? Where is the research for this context? Similarly, new effective, safe, and affordable prevention strategies are much needed. But, this also requires research money and attention. Where should these issues fit in the hierarchy of demands on research time and resources?

None of these questions are new. Ebola and other viruses have raised many of the same ethical challenges. One advantage this time is that the problem with Zika virus was recognized quickly. But, control of Zika virus is still a long way off.

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Noni MacDonald is a Professor in the Department of Pediatrics at Dalhousie University.