Congenital disorders
Notes from the Field: Autism Spectrum Disorder Among …
Nicole M. Roth, MPH1; Camille Delgado-López, MPH2,3; Lisa D. Wiggins, PhD4; Nancy Nieves Muñoz, EdM2; Sarah B. Mulkey, MD, PhD5,6,7; Leishla Nieves-Ferrer, MS2,3; Kate R. Woodworth, MD1; Glorimar Meléndez Rosario, MPH2,3; Mariam Marcano Huertas2,3; Cynthia A. Moore, MD, PhD1,8; Van T. Tong, MPH1; Suzanne M. Gilboa, PhD1; Miguel Valencia-Prado, MD2 (View author affiliations)
View suggested citation
Altmetric:
Citations:
Views:
Views equals page views plus PDF downloads
Infection during pregnancy with Zika virus, a mosquitoborne flavivirus, can cause birth defects and neurodevelopmental abnormalities (1). Autism spectrum disorder (ASD) is a neurodevelopmental disability characterized by social and communication impairment and restricted or repetitive patterns of behavior or interests (2); possible associations between antenatal exposure to a limited number of viruses and ASD have been observed (2). The U.S. Zika Pregnancy and Infant Registry (USZPIR)* monitors children born during January 1, 2016–March 31, 2018, to women with laboratory evidence of Zika virus infection during pregnancy. This report used data from USZPIR and the Puerto Rico Autism Registry† to estimate the prevalence of ASD diagnoses among children with possible prenatal Zika virus exposure and to describe prenatal characteristics and other outcomes by ASD diagnosis status. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§
Investigation and Outcomes
In Puerto Rico, any child who fails a standardized autism-specific screening, regardless of Zika virus exposure, receives a standardized evaluation at Puerto Rico Children with Special Health Care Needs Pediatric Program and Autism Centers¶ to confirm an ASD diagnosis by Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition** criteria. Those who meet ASD criteria are included in the Puerto Rico Autism Registry.
Among 3,122 children reported to USZPIR in Puerto Rico, 109 (3.5%) had received an ASD diagnosis (Table). When analysis was restricted to 1,968 (63.0%) children who received a social-emotional or ASD-specific screener†† at age ≥18 months, 105 (5.3%) received an ASD diagnosis. No statistically significant differences were identified in the proportions of children with differing evidence of Zika virus exposure,§§ maternal symptoms,¶¶ pregnancy trimester of exposure,*** or Zika-associated birth defects between those with and without an ASD diagnosis. A higher percentage of children with an ASD diagnosis were male compared with those without an ASD diagnosis.
Among the 109 children with an ASD diagnosis, most required substantial or very substantial support in social communication (79.8%) and restricted, repetitive behaviors (77.0%). The median age at ASD diagnosis was 39 months (range = 19–73 months), and 33 (30.3%) children with an ASD diagnosis also had a family member with an ASD diagnosis.
Preliminary Conclusions and Actions
This analysis found that among children with Zika virus exposure reported to USZPIR from Puerto Rico, the prevalence of ASD diagnosis ranged from 3.5% to 5.3%, depending on the denominator. Estimated 2018 prevalence of ASD in general population samples in the continental United States ranged from 1.3% to 4.6% among children aged 4 years (3) and from 2.3% to 4.5% among children aged 8 years (4). A systematic analysis found a prevalence of 723 autism cases per 100,000 population (<1.0%) in Latin America and the Caribbean in 2016 (5).
The findings in this report are subject to at least three limitations. First, follow-up to age 5 years is not yet complete, and ASD can be identified even later in childhood. Second, comparators of ASD prevalence in the general Puerto Rico population are not yet available. As of 2023, Puerto Rico is a participating site for the Autism and Developmental Disabilities Monitoring Network††† to conduct ASD surveillance among children aged 4 and 8 years. Finally, delays in referral of children for evaluation because of the COVID-19 pandemic might have lowered the estimated prevalence of ASD.
Additional information is needed to determine whether an association between Zika virus infection in pregnancy and ASD in children exists. Among children with prenatal Zika exposure, screening was reported for only two thirds. ASD-specific screening is recommended for all children to identify concerns as early as possible and minimize delays in intervention.§§§
Acknowledgments
Staff members who conducted data collection for the Puerto Rico U.S. Zika Pregnancy and Infant Registry and Puerto Rico Autism Registry; Puerto Rico Children with Special Health Care Needs Program.
1Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, CDC; 2Puerto Rico Department of Health; 3G2S Corporation, Shavano Park, Texas; 4Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, CDC; 5Children’s National Hospital, Washington, DC; 6Department of Neurology, George Washington University School of Medicine & Health Sciences, Washington, DC; 7Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC; 8Goldbelt Professional Services, LLC, Chesapeake, Virginia.
References
- Mulkey SB, Arroyave-Wessel M, Peyton C, et al. Neurodevelopmental abnormalities in children with in utero Zika virus exposure without congenital Zika syndrome. JAMA Pediatr 2020;174:269–76. https://doi.org/10.1001/jamapediatrics.2019.5204 PMID:31904798
- Shuid AN, Jayusman PA, Shuid N, Ismail J, Kamal Nor N, Mohamed IN. Association between viral infections and risk of autistic disorder: an overview. Int J Environ Res Public Health 2021;18:2817. https://doi.org/10.3390/ijerph18062817 PMID:33802042
- Shaw KA, Bilder DA, McArthur D, et al. Early identification of autism spectrum disorder among children aged 4 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2020. MMWR Surveill Summ 2023;72(No. SS-1):1–15. https://doi.org/10.15585/mmwr.ss7201a1 PMID:36952289
- Maenner MJ, Warren Z, Williams AR, et al. Prevalence and characteristics of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2020. MMWR Surveill Summ 2023;72(No. SS-2):1–14. https://doi.org/10.15585/mmwr.ss7202a1 PMID:36952288
- Olusanya BO, Davis AC, Wertlieb D, et al.; Global Research on Developmental Disabilities Collaborators. Developmental disabilities among children younger than 5 years in 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Glob Health 2018;6:e1100–21. https://doi.org/10.1016/S2214-109X(18)30309-7 PMID:30172774
| Characteristic | All children reported to USZPIR N = 3,122 |
Children with ASQ:SE-2 or M-CHAT-R/F† at age ≥18 mos reported to USZPIR n = 1,968 |
||||||
|---|---|---|---|---|---|---|---|---|
| With ASD diagnosis | Without ASD diagnosis | With ASD diagnosis | Without ASD diagnosis | |||||
| No. | % (95% CI)§ | No. | % (95% CI)§ | No. | % (95% CI)§ | No. | % (95% CI)§ | |
| Total (row %) | 109 | 3.5 (2.9–4.2) | 3,013 | 96.5 (93.1–100) | 105 | 5.3 (4.4–6.5) | 1,863 | 94.7 (90.4–99.1) |
| Laboratory evidence of Zika virus infection | ||||||||
| Possible Zika virus infection¶ | 60 | 55.0 (42.0–70.9) | 1,668 | 55.4 (52.7–58.1) | 57 | 54.3 (41.1–70.3) | 944 | 50.7 (47.5–54.0) |
| Positive Zika virus NAAT result** | 49 | 45.0 (33.3–59.4) | 1,345 | 44.6 (42.3–47.1) | 48 | 45.7 (33.7–60.6) | 919 | 49.3 (46.2–52.6) |
| Maternal symptoms†† | ||||||||
| Signs and symptoms of Zika virus disease | 44 | 40.4 (29.3–54.2) | 1,275 | 42.3 (40.0–44.7) | 44 | 41.9 (30.5–56.3) | 863 | 46.3 (43.3–49.5) |
| No signs and symptoms of Zika virus disease | 65 | 59.6 (46.0–76.0) | 1,738 | 57.7 (55.0–60.5) | 61 | 58.1 (44.4–74.6) | 1,000 | 53.7 (50.4–57.1) |
| Trimester with first evidence of exposure§§ | ||||||||
| 1st¶¶ | 45 | 41.3 (30.1–55.2) | 1,102 | 36.6 (34.5–38.8) | 44 | 41.9 (30.5–56.3) | 685 | 36.8 (34.1–39.6) |
| 2nd | 42 | 38.5 (27.8–52.1) | 1,129 | 37.5 (35.3–39.7) | 40 | 38.1 (27.2–51.9) | 711 | 38.2 (35.4–41.1) |
| 3rd | 22 | 20.2 (12.7–30.6) | 782 | 26.0 (24.2–27.8) | 21 | 20.0 (12.4–30.6) | 467 | 25.1 (22.8–27.5) |
| Child sex | ||||||||
| Female | 35 | 32.1 (22.4–44.7) | 1,502 | 49.9 (47.4–52.4) | 34 | 32.4 (22.4–45.3) | 909 | 48.8 (45.7–52.1) |
| Male | 74 | 67.9 (53.3–85.2) | 1,511 | 50.1 (47.7–52.7) | 71 | 67.6 (52.8–85.3) | 954 | 51.2 (48.0–54.6) |
| Zika-associated birth defects*** | ||||||||
| Yes | 5 | 4.6 (1.5–10.7) | 118 | 3.9 (3.2–4.7) | 4 | 3.8 (1.0–9.8) | 84 | 4.5 (3.6–5.6) |
| No | 104 | 95.4 (78.0–100.0) | 2,895 | 96.1 (92.6–99.7) | 101 | 96.2 (78.4–100.0) | 1,779 | 95.5 (91.1–100.0) |
| ASD outcomes | ||||||||
| Family member with ASD diagnosis | ||||||||
| Yes | 33 | 30.3 (20.8–42.5) | — | — | 31 | 29.5 (20.0–41.9) | — | — |
| No | 58 | 53.2 (40.4–68.8) | — | — | 56 | 53.3 (40.3–69.3) | — | — |
| Unknown | 18 | 16.5 (9.8–26.1) | — | — | 18 | 17.1 (10.2–27.1) | — | — |
| Child’s age group when parent first noticed symptoms, mos | ||||||||
| <6 | 6 | 5.5 (2.0–12.0) | — | — | 6 | 5.7 (2.1–12.4) | — | — |
| 6–12 | 27 | 24.8 (16.3–36.0) | — | — | 26 | 24.8 (16.2–36.3) | — | — |
| 13–18 | 31 | 28.4 (19.3–40.4) | — | — | 29 | 27.6 (18.5–39.7) | — | — |
| 19–24 | 19 | 17.4 (10.5–27.2) | — | — | 18 | 17.1 (10.2–27.1) | — | — |
| 25–30 | 5 | 4.6 (1.5–10.7) | — | — | 5 | 4.8 (1.6–11.1) | — | — |
| 31–36 | 10 | 9.2 (4.4–16.9) | — | — | 10 | 9.5 (4.6–17.5) | — | — |
| 37–42 | 3 | 2.8 (0.6–8.0) | — | — | 3 | 2.9 (0.6–8.4) | — | — |
| 43–48 | 3 | 2.8 (0.6–8.0) | — | — | 3 | 2.9 (0.6–8.4) | — | — |
| 49–54 | 2 | 1.8 (0.2–6.6) | — | — | 2 | 1.9 (0.2–6.9) | — | — |
| Unknown | 3 | 2.8 (0.6–8.0) | — | — | 3 | 2.9 (0.6–8.4) | — | — |
| Age group of ASD diagnosis, mos | ||||||||
| Median (range) | 39 | (19.0–73.0) | — | — | 39 | (19.0–73.0) | — | — |
| 18–25 | 17 | 15.6 (9.1–25.0) | — | — | 17 | 16.2 (9.4–25.9) | — | — |
| 26–33 | 24 | 22.0 (14.1–32.8) | — | — | 22 | 21.0 (13.1–31.7) | — | — |
| 34–41 | 21 | 19.3 (11.9–29.5) | — | — | 21 | 20.0 (12.4–30.6) | — | — |
| 42–49 | 15 | 13.8 (7.7–22.7) | — | — | 15 | 14.3 (8.0–23.6) | — | — |
| 50–57 | 13 | 11.9 (6.4–20.4) | — | — | 12 | 11.4 (5.9–20.0) | — | — |
| 58–65 | 17 | 15.6 (9.1–25.0) | — | — | 16 | 15.2 (8.7–24.8) | — | — |
| 66–73 | 2 | 1.8 (0.2–6.6) | — | — | 2 | 1.9 (0.2–6.9) | — | — |
| Level of support in social communication††† | ||||||||
| Level 1 | 22 | 20.2 (12.7–30.6) | — | — | 22 | 21.0 (13.1–31.7) | — | — |
| Level 2 | 47 | 43.1 (31.7–57.3) | — | — | 46 | 43.8 (32.1–58.4) | — | — |
| Level 3 | 40 | 36.7 (26.2–50.0) | — | — | 37 | 35.2 (24.8–48.6) | — | — |
| Level of support in restrictive, repetitive behaviors††† | ||||||||
| Level 1 | 25 | 22.9 (14.8–33.9) | — | — | 24 | 22.9 (14.7–34.0) | — | — |
| Level 2 | 64 | 58.7 (45.2–75) | — | — | 62 | 59.0 (45.3–75.7) | — | — |
| Level 3 | 20 | 18.3 (11.2–28.3) | — | — | 19 | 18.1 (10.9–28.3) | — | — |
Abbreviations: ASD = autism spectrum disorder; ASQ: SE-2 = Ages and Stages Questionnaires: Social-Emotional, Second Edition; M-CHAT-R/F = Modified Checklist for Autism in Toddlers, Revised with Follow-Up; NAAT = nucleic acid amplification test; USZPIR = U.S. Zika Pregnancy and Infant Registry.
* ASD diagnosis by Diagnostic and Statistical Manual for Mental Disorder, Fifth Edition criteria. https://www.psychiatry.org/psychiatrists/practice/dsm
† https://agesandstages.com/products-pricing/asqse-2/; https://mchatscreen.com/
§ CIs were calculated assuming a Poisson distribution.
¶ Includes maternal, placental, or infant laboratory evidence of possible Zika virus infection during pregnancy based on serologic evidence of a Zika virus infection, or serologic evidence of an unspecified flavivirus infection.
** Includes maternal, placental, or infant laboratory evidence of confirmed Zika virus infection during pregnancy based on presence of Zika virus RNA by a positive NAAT (e.g., reverse transcription–polymerase chain reaction).
†† Signs and symptoms included fever, arthralgia, conjunctivitis, rash, and other clinical signs or symptoms that are consistent with Zika virus disease.
§§ Symptom onset date or date of earliest laboratory evidence of Zika virus infection was used to calculate trimester of exposure.
¶¶ Zika virus infections that occurred during the periconceptual period, which is defined as 4 weeks before last menstrual period, are included in the first trimester of exposure.
*** Zika-associated birth defects include selected congenital brain anomalies (intracranial calcifications, cerebral or cortical atrophy, abnormal cortical gyral patterns, corpus callosum abnormalities, cerebellar abnormalities, porencephaly, hydranencephaly, or ventriculomegaly/hydrocephaly); selected congenital eye anomalies (microphthalmia or anophthalmia; coloboma; cataract; intraocular calcifications; chorioretinal anomalies involving the macula, excluding retinopathy of prematurity; and optic nerve atrophy, pallor, and other optic nerve abnormalities); and microcephaly at birth (birth head circumference below the third percentile for infant sex and gestational age based on INTERGROWTH-21st online percentile calculator unless infants meet criteria for possible measurement inaccuracy. http://intergrowth21.ndog.ox.ac.uk/
††† Level 1: requires support; Level 2: requires substantial support; Level 3: requires very substantial support.
Suggested citation for this article: Roth NM, Delgado-López C, Wiggins LD, et al. Notes from the Field: Autism Spectrum Disorder Among Children with Laboratory Evidence of Prenatal Zika Virus Exposure — Puerto Rico, 2023. MMWR Morb Mortal Wkly Rep 2023;72:802–804. DOI: http://dx.doi.org/10.15585/mmwr.mm7229a5.
MMWR and Morbidity and Mortality Weekly Report are service marks of the U.S. Department of Health and Human Services.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of
Health and Human Services.
References to non-CDC sites on the Internet are
provided as a service to MMWR readers and do not constitute or imply
endorsement of these organizations or their programs by CDC or the U.S.
Department of Health and Human Services. CDC is not responsible for the content
of pages found at these sites. URL addresses listed in MMWR were current as of
the date of publication.
All HTML versions of MMWR articles are generated from final proofs through an automated process.
This conversion might result in character translation or format errors in the HTML version.
Users are referred to the electronic PDF version (https://www.cdc.gov/mmwr)
and/or the original MMWR paper copy for printable versions of official text, figures, and tables.
Questions or messages regarding errors in formatting should be addressed to
[email protected].
