ZIKA Jordan H. Perlow MD Banner University Medical Center Division of Maternal Fetal Medicine Phoenix Perinatal Asoociates
Disclosures I have no relevant financial relationships to disclose or conflicts of interest to resolve. I will not discuss any unapproved or off label, experimental or investigational use of a product, drug, or device.
The Zika virus: - mosquito-borne flavivirus - typically transmitted by the Aedes species of mosquitos - most people do not have symptoms - those who do, typically experience mild, flu-like symptoms; rash - Pregnant women are at risk of pregnancy complications if they contract Zika virus disease during pregnancy - Microcephaly - In February 2016, the World Health Organization declared Zika virus disease to be an international public health emergency.
Flaviviridae / Flavivirus The Flaviviridae are a family of positive, single-stranded, enveloped RNA viruses. They are found in arthropods, (primarily ticks and mosquitoes), and can occasionally infect humans. Members of this family belong to a single genus, Flavivirus, and cause widespread morbidity and mortality throughout the world. Some of the mosquitoes-transmitted viruses include: Yellow Fever, Dengue Fever, Japanese encephalitis, West Nile viruses, and Zika virus(http://www.cdc.gov/zika/index.html). Other Flaviviruses are transmitted by ticks and are responsible of encephalitis and hemorrhagic diseases: Tick-borne Encephalitis (TBE), Kyasanur Forest Disease (KFD) and Alkhurma disease, and Omsk hemorrhagic fever.
Number of travelers to and from Brazil to other countries: Statista (2016). Risk of Zika Virus Infection Through Travelers from Brazil 2014-2015. Available at: https://www.statista.com/statistics/515087/zika-virus-infection-risk-due-to-travelers-from-brazil/ [accessed January 30, 2017].
CDC Information Accessed 2/28/17
Zika Cases Reported in the United States Laboratory-confirmed Zika virus disease cases reported to ArboNET by state or territory (as of February 22, 2017)
Pregnant Women with Any Laboratory Evidence of Possible Zika Virus Infection, 2016-2017 US and DC: 1455 US Territories: 3156 As of 2/7/17 www.cdc.gov/zika
On 12/14/16, CDC issued guidance related to Zika for people living in or traveling to Brownsville, Cameron County, TX. On 11/28, the Texas Department of State Health Services reported the state s FIRST CASE of LOCAL mosquito-borne Zika virus infection in Brownsville. Additional cases have been identified in the area, suggesting that there is a risk of continued spread of Zika virus in Brownsville
First, The Bottom Lines Zika virus is teratogenic and all efforts should be taken by men and women to avoid Zika exposure if they are pregnant or planning pregnancy in the near term ZikaV can be vertically transmitted prenatally and intrapartum Causal link to microcephaly confirmed Other anomalies and adverse perinatal outcomes include: Eye defects / Hearing deficits IUGR Stillbirth Miscarriage Pregnant women should NOT travel to areas with ZikaV A pregnant women should not have sex with a man who has been exposed to ZikaV Women interested in pregnancy should not conceive until??? weeks after potential Zika exposure There is MUCH that remains unknown
April 6, 2016
Over the last 12 months, >1500 MICROCEPHALIC BABIES have been born in Brazil due to Zika Virus Infection
Description of 13 Infants Born During October 2015 January 2016 With Congenital Zika Virus Infection Without Microcephaly at Birth Brazil
Most Current Definition: POSSIBLE exposure to ZikaV Possible Zika Virus exposure = Travel to or residence in an area of active Zika transmission Sex (any type) w/o condom w/ partner who traveled to or lived in area of active Zika transmission
PREVENTION IS KEY Possible Zika Virus exposure = Travel to or residence in an area of active Zika transmission Sex w/o condom w/ partner who traveled to or lived in area of active Zika transmission All men w/ possible Zika exposure considering conception w/ their partner, regardless of sx status, WAIT to conceive until AT LEAST 6 MOS AFTER symptom onset or last possible Zika exposure Women w/ possible Zika exposure should WAIT TO CONCEIVE AT LEAST 8 WEEKS after sx onset or last possible Zika exposure.
Special considerations: Women undergoing fertility tx ZikaV transmission via donated gametes theoretically possible Virus not likely destroyed w/ cryopreservation of gametes Anonymous gamete donors ineligible per FDA if: ZikaV infection in past 6 mos Travel or resident in area w/ active ZikaV transmission within past 6 mos Sex w/ male who had infection within 6 mos of encounter or traveled to area of active ZikaV transmission
Preconception counseling recommendations for testing those attempting conception Perform in persons with possible exposure to ZikaV who have one or more signs / symptoms w/in 2 wk of possible exposure: Acute onset fever, rash, arthralgia, conjunctivitis Routine testing not recommended for women or men attempting conception with possible ZikaV exposure but no clinical illness Test PERFORMANCE unknown in asymptomatic pts NOT KNOWN in men if positive serotest = pos virus in semen or negative test precludes presence of virus in semen RT-PCR testing not validated for semen Positive viral RNA in semen does not indicate infectious virus
Preconception counseling for women and partners residing in affected regions Symptomatic Men wait at least 6 mos after symptoms Women wait at least 8 wks No known current infection Preconception counseling Assess ZikaV exposure risk: May NOT be possible to eliminate risk of ZikaV infection in pregnancy May wish to delay pregnancy Review effective contraception methods Condoms reduces risk for sexual ZikaV transmission
Counseling Persons in Areas of Active ZikaV Transmission Wanting to Conceive
A team of researchers led by Purdue University scientists Michael Rossmann and Richard Kuhn is the first to determine the structure of the Zika virus, which reveals insights critical to the development of effective antiviral treatments and vaccines.
Preconception Counseling and Prevention is Key, but.. What if? POSSIBLE EXPOSURE in Pregnancy Testing regimens are changing Protocols are constantly being updated Stay current Use consultants cdc.gov/zika MMWR email updates ACOG/SMFM Most Current Algorithm MMWR July 29, 2016
Who and How to Test July 29, 2016 www.cdc.gov/zika
Clinical Management Guided by Testing July 29, 2016 www.cdc.gov/zika
Isolated Microcephaly = HC >3SD below mean Pathologic microcephaly = HC >5SD IF HC >2SD below mean Detailed neurosonographic exam; if nl, f/u in 3-4 wk Look for echogenic foci, other findings Look for sloping forehead in profile assessment TABLE Serial u/s q 3-4 wk w/ e/o maternal infection Consider same for women at risk with neg testing Data very limited; recs evolving
Magnitude of Zika Perinatal Risk? 1% risk microcephaly with first trimester maternal infection French Polynesia 8 fetuses affected Mathematical modeling determination of risk Cauchemez M, et al. Lancet March 15, 2016 Brazil: 42 women with lab-confirmation of ZikaV in pregnancy (any trimester) w/ u/s data 29% w/ abnormal findings Microcephaly / intracranial calcifications, other brain abnormalities, IUGR, IUFD Brasil P et al. NEJM 2016 Microcephaly likely part of a spectrum of abnormal neurological development Likely UNDERestimates risk
Exposure / Infection around time of conception: Magnitude of Risk Currently unknown Possible adverse outcomes 2 women w/ ZikaV infection at <7 wks w/ sabs reported ZikaV RNA detected in POCs Another pt w/ infection at 7-8 wks Term delivery / severe microcephaly Meaney-Delman D et al. MMWR 2016 Preconception Counseling Challenging due to limited information Need for constant update of fund of knowledge CDC.gov, NEJM.org, Lancet
Large scale prenatal screening program at a single center Parkland Began 3/14/16 Published 3/2017; AJOG Report on baseline prevalence of travel associated Zika infection in pregnancy Determine travel characteristics of women w/ evidence of Zika infection Evaluate maternal and neonatal outcomes vs. women w/o e/o Zika infection
Feb. 12, 2016 file photo, Lara, who is less then 3-months old and was born with microcephaly, is examined by a neurologist at the Pedro I hospital in Campina Grande, Paraiba state, Brazil. Scientists suspect an outbreak of the Zika virus is behind a surge in a rare birth defect in Brazil
Zika Virus and Microcephaly