Zika Virus: Epidemiology and Preparedness NH Emergency Preparedness Conference June 9, 2016 Abigail Mathewson, DVM, MPH Surveillance Epidemiology Program Manager State Public Health Veterinarian Abigail.mathewson@dhhs.nh.gov (603) 271-0274 Carolyn Fredette, MPH Vectorborne Disease Surveillance Coordinator Carolyn.fredette@dhhs.state.nh.us (603) 271-0273 Zika Basics Virus transmitted by the bite of an infected Aedes mosquito Predominantly Aedes aegypti but Aedes albopictus and other Aedes possible Same mosquitos that transmit Chikungunya, malaria, dengue Two lineages African lineage Asian lineage 1
Zika History First isolated in 1947 from a monkey in Ziika forest, Uganda and in 1948 from the Aedes africanus mosquito The first human case of Zika virus was identified in 1954 in Nigeria Image source: J Cohen Science 8 Feb 2016 Zika History 2
Zika History Yap Island Outbreak, 2007 75% of Yap Island s 7,000 citizens were infected with Zika Asian lineage 18% actually developed symptoms (82% were asymptomatic) Zika History French Polynesian Outbreak, 2013 28,000 cases with symptomatic infection As many as 140,000 infected 70 cases were hospitalized with severe illness 38 developed Guillain-Barre syndrome (GBS) 32 developed neurological symptoms Asian lineage 3
Current Outbreak Since Aug 2014 rapid spread in S. and Central America Arrived via FIFA World Cup Brazil heavily impacted First ever deaths (2) from Zika confirmed Total number of deaths due to current outbreak is now up to 4 Association with microcephaly noted Concurrent unprecedented dengue epidemic 48 countries and territories affected including US Virgin Islands and Puerto Rico WHO estimates 3 4 million cases of Zika in next 12m Asian lineage Countries Currently Affected List available: http://www.cdc.gov/zika/geo/active-countries.html 4
Zika in the United States (as of 6/1/16) US States Travel-associated cases reported: 618 4 in New Hampshire Locally-acquired vector-borne cases reported: 0 US Territories Travel-associated cases reported: 4 Locally acquired cases reported: 1,110 NH Zika Epidemiology As of June 8, 2016 NH as identified four cases of Zika virus in NH residents Case #1: Identified March 1, 2016 Sexual transmission Non-pregnant female Partner traveled to Zika affected area Sexual intercourse during the time the partner was symptomatic Case #2: Male traveler Cases #3 and 4: Pregnant female travelers 5
NH Zika Epidemiology Additional Transmission Mechanisms Sexual transmission reported in 11 cases It is unknown how long the virus remains present in semen after symptom onset Possibly up to 2 months Many questions remain Identified in other body fluids but the role for transmission is unknown Urine and saliva Breast milk No confirmed transmission and risk-benefit favors breastfeeding 6
Transmission Mechanisms Signs and Symptoms 7
Symptoms of Zika Virus Incubation ~3-12 days after bite 60-80% of infections asymptomatic Symptoms usually mild Self-limiting febrile illness of 4 7 days duration Acute fever, maculopapular rash, conjunctivitis, joint / muscle pain, and headache Image source: CDC Symptoms of Zika Virus Severe Manifestations Severe manifestations: Guillain-Barré syndrome Develops rapidly over hours or days Symmetric paralysis Orthostatic hypotension or urinary retention may occur Microcephaly and other neuro conditions in babies from infected mothers Especially first 2 trimesters of pregnancy Image source: CDC 8
Testing and Recommendations Changes in Testing Testing facilitation began in late December, 2015 Specimens shipped to NH PHL for triage All specimens transferred to CDC Dec. 2015 beginning of March, 2016 Beginning in March (3/2), urine specimens were shipped to Wadsworth Lab in NY NH PHL began RT-PCR testing of serum and urine on April 18, 2016 MA PHL began serology and PRNT on April 4, 2016 9
Source: CDC Source: CDC 10
Current Testing Guidelines Symptom Onset Test Specimen Type <5 days RT-PCR Serum and Urine 5-6 days RT-PCR and Serology Serum and Urine Serum 7-13 days RT-PCR and Serology if negative, Urine Serum serology may need to be repeated after 14 days have elapsed 14 days Serology Serum Prevention Sexual Transmission of Zika Virus Male Partner s Status Traveled to a Zika affected area + Symptoms of Zika virus infection Pregnant sex partner Correctly use condoms or abstain from sex for duration of pregnancy Non-pregnant sex partner Correctly use condoms or abstain from sex for at least 6 months after onset of illness Traveled to a Zika affected area (no symptoms of Zika virus infection) Correctly use condoms or abstain from sex for duration of pregnancy Correctly use condoms or abstain from sex for at least 8 weeks after return from Zika affected area 11
Recommendations for Pregnant Women Pregnant woman should consider postponing travel to affected areas Pregnant woman who traveled to an affected area should be tested for Zika and followed closely by OB Testing capability currently limited U.S. Zika Pregnancy Registry (USZPR) Purpose To update clinical guidance and recommendations To plan for outreach and services for pregnant women and families affected by Zika virus To improve Zika virus prevention efforts, specifically during pregnancy 12
U.S. Zika Pregnancy Registry (USZPR) Eligibility Pregnant women in the U.S.with laboratory evidence of Zika virus infection and their infants Infants with laboratory evidence of congenital Zika virus infection and their mothers Role of the health department Report information about pregnant women and infants with laboratory evidence of infection Collect enhanced surveillance data about pregnant women and their infants Work with CDC to determine methods for collecting and sharing data New Hampshire Response State coordination BIDC, PHL, MCH Testing facilitation Established testing capability in PHL Clinician communication Health Alerts Webinar Consultation Public communication Social media, media, press release, etc. 13
Future Planned Activities Additional Incident Command System (ICS) training for staff ICS 300 and ICS 400 Reestablish the NH Birth Defects registry Develop a new arboviral Web-based Interactive System for Direction and Outcome Measures (WISDOM) dashboard Vector Biology, Ecology and Control 14
Topics Covered Basics of vectorborne disease and mosquitoes Current/prior surveillance activities Zika vectors in the US Disease transmission cycles (endemic vs Zika) Control measures Vectorborne Disease Three components of vectorborne disease Pathogen Host Vector https://www.sercc.com/climate_health/ 15
Mosquitoes: The Basics wumcd.org NH Arboviral Surveillance Activities Surveillance and control Mosquito Town-based program decisions and financing Human and veterinary Outreach and coordination with healthcare providers (Health Alert Network messaging) Public education and prevention messaging Distribution of surveillance data Test results and risk map updated weekly July-Sept Press releases NH Public Health Laboratories testing Mosquito, human, veterinary samples 16
NH Town Sponsored Mosquito Trapping, 2015 17
Aedes albopictus At the beginning of 2016, the CDC listed NH as within the potential range of this vector. Previously the northernmost range was thought to run along the 0⁰ January isotherm (NJ) although CT has reported presence, and more recently MA Currently trying to identify means to enhance NH s surveillance * * Prior Geographic Distribution Estimates CDC Ingrid Rabe 18
Estimated range of Ae. albopictus in the U.S. Estimated range of Ae. aegypti in the U.S. 19
Predicted Global Distribution of Aedes aegypti Kraemer et al 2015 Other Potential Vectors? Currently unknown, but is possible Research is ongoing 20
Many Factors Influence Transmission Factors Influencing Vector Capacity Kramer and Ciota 2015 21
Transmission Cycle Boiled Down WNV/EEE Aedes Culex Coquillettidia Culiseta (we test more than this) Bridge Enzootic Bridge Simple Transmission Cycle No bridge vectors Avoid mosquitoes! www.cdc.gov 22
Why is this a concern? It is possible to have sustained local transmission of arboviral illnesses outside of the sylvatic cycle This happened in Italy with CHIK until frost ended the mosquito season This is happening with the current outbreak of great significance, especially for areas with out a cold season Risk of developing a sylvatic cycle in areas with non-human primates Control Measures 23
Opportunities for Control X X X X www.biogents.com Common Mosquito Habitats and Breeding Spots Storage or trash containers Tarps Toys Plastic pools Fountains, bird baths Potters without drainage holes Animal drinking bowls Septic tanks Water meters 24
Steps to Prevent Mosquito Bites Wear protective clothing Long pants, long-sleeved shirts Keep mosquitoes outdoors Install air-conditioning units and window and door screens If you re going to be outdoors, sleep under a mosquito bed net Use an EPA registered insect repellent according to the product label Personal Protective Measures: Insect Repellents DEET Oil of Lemon Eucalyptus Picaridin Permethrin Applied to clothing Permethrin impregnated clothing Do not use directly on skin Source: CDC 25
Protect Children from Mosquito Bites Do not use insect repellent on babies younger than 2 months old Do not use repellents containing oil of lemon eucalyptus on children under the age of 3 Cover cribs, strollers, and baby carriers with mosquito netting Never spray insect repellent directly onto a child s face. Adults should spray insect repellent onto their hands and then apply it to the child s face NH DPHS Preparation Activities Our Incident Management Team has been activated and new information is disseminated as it becomes available Actively seeking out means to begin targeted vector surveillance Development of extensive education campaigns Performing extended case follow-up and connecting cases to appropriate care and/or resources Disseminating data at least weekly Providing relevant clinical and epidemiological updates as information becomes available Development of a NH Zika Virus Response Plan 26
Questions? Contact information: NH Bureau of Infectious Disease Control (603) 271-4496 27