Zika Update PSSNY 2016 Annual Convention June 25, 2016 Suzanna Gim, PharmD, MPH Email: suzannagim@gmail.com
Learning Objectives Describe the epidemiology and prevalence of Zika virus disease Identify the factors associated with suspected Zika virus infection State the criteria for Zika virus testing List the recommendations and considerations for prevention of Zika virus disease and transmission 2
Timeline First discovered in Zika forest, Uganda 1947 Sporadic cases in Africa and Southeast Asia 2007 Outbreak in Yap Island 2013-2014 French Polynesia >28,000 suspected cases 2015 Spread to Americas through Brazil 2016 WHO declares Public Health Emergency of International Concern 3
CDC Reported Active Transmission Cdc: at a glance right panel #s http://www.cdc.gov/zika/index.html 4
ArboNET Reported Lab Confirmed Zika Cases in US & Territories 5
Background Flavivirus (RNA virus) Arbovirus Principal vector: Aedes species mosquitoes Aedes aegypti Also called: Yellow fever, Asian tiger mosquitoes Concentrated in Southern/Eastern US/ Africa/ Asia Also carry dengue, yellow fever, chikungunya, Japanese encephalitis, West Nile 6
Principal Vector: Aedes Mosquito 7
Transmission Bites from infected mosquitoes Sex from male to partner Direct contact with infectious blood or semen From pregnant woman to fetus In utero; highest risk during first trimester* At delivery Previous infection unlikely to affect future pregnancies *Based on preliminary data from Rio de Janeiro & Colombia 8
US Zika Virus Testing & Infection CDC report: Jan 3 Mar 5, 2016 Study population: Persons who traveled to or moved from Zika-affected areas, tested in US/DC Group tested N N (%) with confirmed Zika All participants 4,534 197 (4) Symptomatic 1,541 182 (12) Asymptomatic 2,557 7 (<1) Pregnant 3,335 28 (1) Symptomatic 620 18 (3) Asymptomatic 2,425 7 (<1) 9
Presentation 1 out of 5 infected develop symptoms Symptoms (usually mild): Fever, rash, joint pain, conjunctivitis, myalgia, headache Begin 2-7 days after bite Last 2-7 days Neurological/ autoimmune complications infrequent Guillain-Barre syndrome 10
Yap Island 2007 Duffy M. N Engl J Med 2009. 11
Zika vs Dengue vs Chikungunya 12
Differential Diagnoses Dengue Chikungunya Leptospirosis Malaria Rickettsia Parvovirus Group A streptococcus Rubella Measles Adenovirus Enterovirus 13
Suspected or Confirmed Zika Infection Management Supportive Rest Fluids to prevent dehydration Acetaminophen to reduce fever and pain Avoid taking aspirin and NSAIDs until dengue is ruled out Prevent transmission Avoid mosquito bites during first week of infection Males: Avoid sexual contact for 6 months after infection 14
Diagnostic Testing Reverse transcriptase-polymerase chain reaction (RT-PCR) Serum, tissue, urine* Must be collected within 1 week of exposure Results can take weeks Commercially available test for serum only Should also test for dengue and chikungunya Only CDC, state and federal health authorities test using other methods NYC DOH Zika Testing for Providers: 1-866-692-3641 Pregnant women with symptoms take priority *Positive results for longer period of time 15
Who to Test GROUP Pregnant women (with or without symptoms) Men & non-pregnant women Fetus, neonate or infant Person with GBS CRITERIA Traveled to Zika-affected area Had unprotected sex during current pregnancy with partner who traveled to or lived in Zika-affected area > 1 compatible symptom within 4 weeks of travel to Zika-affected area With microcephaly or intracranial calcifications born to woman with possible Zika exposure during pregnancy through sex or travel GBS onset after travel to Zika-affected area 16
Adverse Outcomes Infection during pregnancy Causally linked to microcephaly; May be higher risk during first trimester More severe symptoms associated with more severe fetal outcomes Associated with other severe birth defects, fetal death Cases of Guillain-Barre associated with infection 42 cases reported in the French Polynesian outbreak Also reported in South America during current outbreak Death reported but rare 17
Special Precautions for Pregnant Women 18
Pregnant with Zika: Now what? More frequent ultrasounds Microcephaly undetectable until 2 nd trimester Not every infected fetus results in microcephaly Amniocentesis on case by case basis; maternal Zika is not in itself an indication Counseling for pregnancy termination or child prognosis Close follow-up until birth and consultations with maternal-fetal specialist Follow-up of child 19
Range of Microcephaly Severity Severe: Need developmental services early in life (speech, occupational, physical therapy, potential seizures) Linked with developmental delays, problems with movement/ balance, feeding, hearing, vision; May be lifelong or fatal. 20
Microcephaly Diagnosis During pregnancy: Ultrasound late 2 nd / early 3 rd trimester After birth (> 24 hours): Head circumference < 2 SD s below average by age & sex < 3 rd percentile by age & sex Incidence unknown 2-12 babies per 10,000 live births in US Causes unknown Genetic abnormalities Certain infections during pregnancy (e.g. Rubella, toxoplasmosis, cytomegalovirus) Severe malnutrition Exposure to toxic chemicals, certain drugs, alcohol Interruption of blood supply to baby s brain during development 21
Guillain-Barre Syndrome 1-2 cases per 100,000 people in US Cause unknown; Link to Zika unclear Person s own immune system damages nerve cells Generalized weakness that may last weeksmonths Most people fully recover, some have permanent damage and 1 of 20 cases are fatal Onset appears days to weeks after sickness is over making causal relationships unclear http://www.cdc.gov/zika/about/gbs-qa.html 22
Current Status Lab confirmed Zika virus cases reported to ArboNET* (June 15, 2016) US and DC: 756 (Sexually transmitted= 11; GBS= 3) US territories: 1,440 (GBS= 6) NYC: 151 Pregnant women with lab confirmed Zika Virus infection (CDC June 9, 2016) US and DC: 234 US territories: 189 NYC: 19 *National surveillance system for arboviral diseases Note: All pts contracted outside of US; All recovered 23
Prevention Mosquito bites (day biter): Physical barriers: Window/ door screens, air conditioning, bednets, long sleeved shirts/ pants (pre-treated) Chemical protection: DEET, picardin, oil of lemon eucalyptus, permethrin (clothing/ gear) Infected persons should be protected from further mosquito exposure during the first week of illness to reduce the risk of local transmission Mosquito eggs: Dump / scrub all still water containers weekly Eggs may lay dormant up to a year Educate: only need bottle cap size of still water Sexual transmission male-male/ male-female: Detected in semen of male patients up to 62 days after onset of fever Correct use of condoms/ abstinence and birth control Nosocomial transmission 24
Effective Mosquito Repellant Use EPA approved products DEET efficacy plateaus at 50% Amount usually equates to longer protection Safe during pregnancy Do not use on skin under clothing Do not spray on face; Spray on hands then apply on face Apply sunscreen first, then repellant; Reapply sunscreen more frequently Government mosquito control funding limited by cities/ region Pesticide spraying helicopters 25
Sexual Transmission Prevention Recommendations While in Zika Affected Areas After returning home from Zika Affected Areas Non-Pregnant Women & Men: Non-Pregnant Women: Men with symptoms or positive Zika test: Men without symptoms or negative Zika test: Use birth control and condoms correctly Use birth control for 8 weeks Use condoms for 6 months Use condoms for 8 weeks 26
Patients Interested in Conceiving Clinical context Women with Zika or consistent illness Men with Zika or consistent illness Men & Women who traveled to Zika-affected area but did not become ill Recommended wait time before attempting conception > 8 weeks > 6 months > 8 weeks 27
Nosocomial Transmission Prevention No reports of transmission from Zika infected patient to a healthcare worker Labor and delivery workers may have higher risk Standard precautions recommended: Gowns, gloves, foot coverings, facemask with eye protection or face shield 28
NYC DOH Response Monitor spread of Zika virus in NYC Increase public awareness through community outreach; Fight Back NYC Pregnant women who don t use prenatal care Educate providers and assist with diagnosis Coordinate and perform lab testing Monitor pregnant women with Zika infection and their babies Monitoring mosquito populations and applying pesticides during the summer months https://www1.nyc.gov/site/doh/health/health-topics/westnile-virus-spray.page 29
What about the Olympics? Postpone 2016 Summer Olympics? Will be winter in Brazil Event areas will have good mosquito control Most will already have immunity Pregnant women and partners should not attend Attendees should not have sex for 6 months after Country bans on childbearing? Life expectancy of infected babies? Extent of brain damage associated with the infection? Vaccine? 30
What you & your organization can do Counsel patients on prevention Refer suspected cases to providers for testing Report cases to NYC Department of Health Refer exposed mothers and congenitally exposed children to specialty care Timely reporting allows health departments to assess and reduce risk of local transmission or mitigate further spread 31
Resources MotherToBaby service by the CDC http://mothertobaby.org/ to chat live or send email Call 1-866-626-6847; Text 855-999-3525 CDC: https://www.cdc.gov/zika/index.html NYC DOH: https://www1.nyc.gov/site/doh/health/health-topics/zika-virus.page NYS DOH: https://www.health.ny.gov/diseases/zika_virus/ Zika hotline: 1-888-364-4723 - Monday Friday (9-5pm) WHO release statement: http://www.who.int/mediacentre/news/statements/2016/zika-third-ec/en/ PAHO: http://www.paho.org/hq/index.php?option=com_content&view=article&id=11 585&Itemid=41688&lang=en 32
References Duffy MR, Chen TH, Hancock WT, et al. Zika virus outbreak on Yap Island, Federated States of Micronesia. N Engl J Med 2009; 360:2536-2543. Brasil P, Pereira JP, Raja Gabaglia C, et al. Zika virus infection in pregnant women in Rio de Janeiro - Preliminary Report. N Engl J Med. 2016 Mar 4. [Epub ahead of print] Pacheco O, Beltrán M, Nelson CA, et al. Zika virus disease in Colombia Preliminary Report. N Engl J Med. 2016 Jun 15. [Epub ahead of print] Foy BD, Kobylinski KC, Chilson Foy JL, et al. Probable non-vector-borne transmission of Zika virus, Colorado, USA. Emerg Infect Dis 2011;17:880-2. Hills SL, Russell K, Hennessey M, et al. Transmission of Zika Virus Through Sexual Contact with Travelers to Areas of Ongoing Transmission - Continental United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:215-6. Trew Deckard D, Chung WM, Brooks JT, et al. Male-to-Male Sexual Transmission of Zika Virus Texas, January 2016. MMWR Morb Mortal Wkly Rep 2016;65:372-4. Atkinson B, Hearn P, Afrough B, et al. Detection of Zika virus in semen[letter]. Emerg Infect Dis 2016. Published online March 2016. 33