Zika Pregnancy and Birth Defects Surveillance Sowmya Adibhatla, MPH Zika Surveillance and Response Coordinator Overview History/Background Zika cases update Zika virus infection Testing guidance Recommendations for pregnancy April 23, 2018 Overview Wisconsin response and surveillance o U.S. Zika Pregnancy and Infant Registry (USZIPR) o Wisconsin Zika Pregnancy and Infant Registry o Zika Birth Defects Surveillance (ZBDS) Communication and messaging History First identified in Uganda in 1947 in a monkey Prior to 2007, only sporadic cases were reported in Africa, Asia, and Pacific Islands. During May 2015, the World Health Organization reported the first local transmission of Zikavirus in the Americas. In February 2016, the Director-General of the World Health Organization declared Zika a Public Health Emergency of International Concern. History Estimated Range of Aedes Mosquitoes in the United States (2017) Aedes albopictus Aedes aegypti 1
Background Zika virus can be transmitted by: o Certain Aedes species of mosquitoes. o Maternal-fetal: during pregnancy and time of birth. o Sexual contact (by both male and female). Zika infection in pregnancy can cause microcephaly and other severe fetal birth defects. Other problems detected in fetuses and infants infected with Zika virus before birth include: miscarriage, stillbirth, absent or poorly developed brain structures, eye defects, hearing deficits, impaired growth, and inflexible joints. Wisconsin Zika Cases Update Fee-exempt laboratory testing is currently performed by the Wisconsin State Laboratory of Hygiene for qualifying patients. Wisconsin Travel-RelatedZika Virus Updated April 04, 2018 2016 2017 2018 Confirmed Cases 63 9 0 Probable Cases* 0 1 0 Total Tested 1062 935 20 *Probable cases have presumptive positive laboratory results without confirmatory CDC testing. Symptoms: Fever Rash Joint pain Red eyes Muscle pain Headache Zika Virus Infection Any of these four symptoms appearing within two weeks of travel or sexual exposure qualifies a patient for fee-exempt testing. Fetal abnormalities will also qualify an exposed pregnant women for fee-exempt testing. adapted for the Wisconsin population from CDC interim clinical guidance Fee-exempt testing available for the following groups: Symptomatic patients with possible Zika virus exposure (travel or sexual), should be tested As soon as possible within 12 weeks of onset, Using concurrent Zika virus nucleic acid test (NAT) and IgM antibody testing. adapted for the Wisconsin population from CDC interim clinical guidance Asymptomatic pregnant women with unavoidable ongoingexposure (i.e., travel repeatedly to a risk area for family or work obligations) should be tested Up to three times during pregnancy, Using Zikavirus (NAT) testing (IgM antibody testing is not routinely recommended for this purpose). adapted for the Wisconsin population from CDC interim clinical guidance, July 2017 Update: Testing is no longer routinely recommended for asymptomatic pregnant women. However, testing may be considered using a shared patient-provider decision-making model. Justification: 1. Declining prevalence of Zika in the Americas 2. Emerging evidence of prolonged detection of Zika IgM 2
Recommendations for Pregnancy Pregnant women should not travel to areas where Zika is spreading. If a partner is exposed to Zika, protected sex is recommended (for all types of encounters) for the duration of the pregnancy. For individuals planning to become pregnant: Women should delay conception for eight weeks following sexual or travel exposure. Men should delay conception for six months following sexual or travel exposure. As many as one in 10 babies of women with possible Zika virus infection during pregnancy had Zikaassociated birth defects. Birth defects appear more likely in babies whose mothers were infected during the first trimester of pregnancy (8% in first trimester, 5% in second trimester, 4% in third trimester). Severe cases described by: Severe microcephaly where the skull has partially collapsed Decreased brain tissue with a specific pattern of brain damage Damage (i.e., scarring, pigment changes) to the back of the eye Joints with limited range of motion, such as clubfoot Joint contractures restricting body movement soon after birth Babies of infected mothers may appear healthy and later develop complications. Guide to care of babies who appear healthy: At birth: Comprehensive physical exam Standard newborn hearing assessment Zika virus laboratory testing (blood and urine) 1 month: o Routine well-baby exam o Eye exam by ophthalmologist o ABR hearing screen o Head ultrasound 2, 4, 6, 9, and 12 months: Routine well-baby exam U.S. Zika Pregnancy and Infant Registry The Centers for Disease Control and Prevention (CDC) established the USZPIR to learn more about pregnant women with Zika and their infants, including how likely a baby is to develop microcephaly or another defect. The USZPIR captures information on pregnancies with any lab evidence of Zika virus infection: o During pregnancy. o At delivery. o Through the infant s first two years of life. 3
U.S. Zika Pregnancy and Infant Registry The (DHS) is coordinating data collection with CDC. Enrollment of pregnant women to the USZPIR ended on March 31, 2018. Wisconsin Zika Pregnancy Registry 1.Confirmed case from Bureau of Communicable Diseases is received. 2. Onboard calls to provider are performed. 3. CDC data collection forms are completed. o Pregnancy Maternal health history Supplemental imaging Neonate assessment o Follow-up after birth: infant follow-up at 2, 6, 12, 18, and 24 months U.S. Zika Birth Defects Surveillance Enhanced surveillance activities include state-level rapid, active population-based ascertainment of microcephaly and other adverse outcomes linked to maternal Zika virus (with and without lab evidence of Zika). Data will be used for referral to services for infants with microcephaly or other adverse outcomes linked with Zika virus. U.S. Zika Birth Defects Surveillance CDC has identified a list of birth defects that may be associated with Zika virus infection but have other causes as well. These types of birth defects occur in Wisconsin each year. Further investigation will identify if any of these cases have an epidemiological link to Zika virus. Surveillance is currently focused on infants born between January 1, 2016, and December 31, 2017. Zika Birth Defects Surveillance Zika-associated birth defects cases are identified through various sources, including: Vital statistics (birth, death certificates). Hospital discharge data. USZPIR and Wisconsin Birth Defects Registry. Zika Birth Defects Surveillance Medical records are requested for identified cases, including: o Prenatal record/postpartum record. o Labor and delivery record. o Pathology/lab/medical imaging reports. CDC data collection forms are completed (same as USZPIR). 4
Communication and Messaging Statewide memo to prenatal care providers with recommendations for assessing pregnant women for Zika exposure Winter and spring break educational fliers: Wisconsin Zika Response Bureau of Communicable Disease o Christine Muganda and Rebecca Osborne: Vectorborne epidemiologists o Ryan Wozniak: Unit chief o Connie Bell: Communications o Angie Rohan: CDC-assignee MCH epidemiologist o Kim Meinholz: Zika data abstractor Office of Preparedness and Emergency Health Care DHS Zika Website: https://www.dhs.wisconsin.gov/zika/index.htm Sowmya Adibhatla sowmya.adibhatla@dhs.wi.gov Ph: 608-261-6879 5