11/12/2016 1 ZIKA VIRUS DISEASE: What every clinician should know Francisco García, MD, MPH Director & Chief Medical Officer Objectives Zika virus epidemiology Diagnoses and testing Zika and pregnancy Sexual transmission What to tell patients» about Zika» about mosquito bite protection 1
ZIKA VIRUS EPIDEMIOLOGY Zika Virus (Zika) Single stranded RNA virus Genus flavivirus, family Flaviviridae Closely related to dengue, yellow fever, Japanese encephalitis, and West Nile viruses Primarily transmitted through the bite of an infected Aedes species mosquito (Ae. aegypti and Ae. albopictus) Aedes aegypti Aedes albopictus 2
Routes of Transmission Bite from an infected mosquito Maternal-fetal:» Periconceptional,» Intrauterine;» Perinatal;» Lactation Sexual transmission Laboratory exposure Blood transfusion Incidence & attack rates, Yap 2007 Infection rate: 73% (95%CI 68 77) Symptomatic attack rate among infected: 18% (95%CI 10 27) All age groups affected Adults more likely to present for medical care No severe disease, hospitalizations, or deaths Note: Rates based on serosurvey on Yap Island, 2007 (population 7,391) 3
Incubation and viremia Incubation period for Zika virus disease: 3 14 days. Zika viremia ranges from days to 1 week. Some infected pregnant women have evidence of Zika virus in their blood longer than expected. Virus remains in semen and urine longer than in blood. 3 14 days Clinical course and outcomes Clinical illness is usually mild. Symptoms last days to a week. Severe disease requiring hospitalization uncommon. Fatalities rare. Guillain-Barré syndrome strongly associated with Zika; however only a small proportion of people with recent Zika infection get GBS. 4
Symptoms Most infections asymptomatic. Most common symptoms» Acute onset of fever» Maculopapular rash» Joint pain» Conjunctivitis Other symptoms:muscle pain and headache. Reported clinical symptoms among confirmed ZVD cases Yap Island, 2007 Duffy M. N Engl J Med 2009 5
Clinical features: ZVD, dengue and chikungunya Rabe, Ingrid MBChB, MMed Zika Virus- What Clinicians Need to Know? (presentation, Clinician Outreach and Communication Activity (COCA) Call, Atlanta, GA, January 26 2016) DIAGNOSES AND TESTING FOR ZIKA 6
Assessing pregnant women All pregnant women should be asked about exposure risk at each prenatal care visit» Traveled/commute/live in an area with Zika during their pregnancy or periconceptional period (the 6 weeks prior to last menstrual period or 8 weeks prior to conception)» Had sex without a condom with a partner who has traveled to or lives in an area with Zika Pregnant women who have possible exposure to Zika virus are eligible for testing. Who to test for Zika CDC does not recommend testing for asymptomatic men, children, and non pregnant women. 7
Differential diagnosis Based on typical clinical features, the differential diagnosis for Zika virus infection is broad. Considerations include Dengue Chikungunya Leptospirosis Malaria Riskettsia Group A Streptococcus Rubella Measles Parvovirus Enterovirus Adenovirus Other alphaviruses (e.g., Mayaro, Ross River, Barmah Forest, o nyong-nyong, and sindbis viruses) Diagnostic testing for Zika virus During first 2 weeks, Zika virus infection can often be diagnosed by performing real-time reverse transcriptase polymerase chain reaction (rrt-pcr) on serum and urine. Serology assays can be used to detect Zika virus-specific IgM and neutralizing antibodies, which typically develop toward the end of the first week of illness. Plaque reduction neutralization test (PRNT) for presence of virus-specific neutralizing antibodies in paired serum samples, used as confirmatory testing. 8
Reporting cases ZVD is a nationally notifiable condition. Report all confirmed cases to your health department. 11/12/2016 18 Pima County Human Surveillance, 2016 Current 131 Active investigations 106 female 73 pregnant 29 minors Case Ascertainment 8 positive Zika travel related cases 4 unspecified flavivirus, CDC confirmed A Healthy Pima County. Every one. Every where. Every day. 9
11/12/2016 19 Travel Associate Zika Case Investigations by Region United States Florida (8) Arizona (16) (no travel) Mexico Chiapas Colima Jalisco Guerrero Oaxaca (3) Quintana Roo (8) Sonora (26) Chihuahua Veracruz Central America Belize(2) Costa Rica (2) Ecuador El Salvador (6) Guatemala (11) Honduras (5) Nicaragua (2) South America Brazil (4) Guyana (2) Columbia Caribbean (3) Barbados Dominican Republic (3) Jamaica (5) Puerto Rico (5) St. Thomas Asia A Healthy Pima County. Every one. Every where. Every day. ZIKA AND PREGNANCY 10
Zika and pregnancy outcomes Virus can pass to fetus during pregnancy or around time of birth. Infection in pregnancy causes microcephaly & other severe brain defects. Other problems:» Miscarriage, stillbirth, birth defects including absent or poorly developed brain structures, defects of the eye, hearing deficits, limb abnormalities, and impaired growth. Zika and pregnancy Knowledge about Zika virus is increasing rapidly and researchers continue to work to better understand the extent of Zika virus impact on mothers, infants, and children. No reports of infants getting Zika through breastfeeding. No evidence that previous infection will affect future pregnancies. 11
Zika pregnancy registry CDC is monitoring pregnancy and infant outcomes following Zika infection during pregnancy in US states and territories» US Zika Pregnancy Registry» Zika Active Pregnancy Surveillance System, Puerto Rico. CDC maintains a 24/7 consultation service for health officials/healthcare providers caring for pregnant women. 800-CDC-INFO (800-232-4636),or email ZIKAMCH@cdc.gov. EVALUATION AND FOLLOW UP OF INFANTS WITH CONFIRMED OR POSSIBLE ZIKA INFECTION 12
Interim Guidance: Evaluation and testing of infants with possible congenital Zika virus infection Congenital Zika Syndrome Recently recognized pattern of congenital anomalies associated with Zika virus infection during pregnancy, includes:» Microcephaly» Intracranial calcifications» Other brain anomalies» Eye anomalies» Other findings 13
SEXUAL TRANSMISSION About sexual transmission Can be passed through sex from a person who has Zika to his/her partners.» Can be passed from infected person with Zika before symptoms start, while symptomatic, and after symptoms end.» Virus may also be passed by a person who never has symptoms. Includes sex without a condom with a person who traveled to or lives in an area with Zika. 14
Zika in genital fluids Unclear how long Zika stays in semen and vaginal fluids and how long it can be passed to sex partners. Zika can remain in semen longer than in other body fluids, including vaginal fluids, urine, and blood. Four published reports of Zika virus cultured from semen, virus was reported in semen up to 69 days after symptom onset. Preventing/reducing sexual transmission Not having sex eliminates risk of sexual transmission. Condoms reduce risk of transmission.» Dental dams (latex or polyurethane sheets) may also be used for oral sex.» Not sharing sex toys reduces the risk of transmission. Pregnant couples with a partner who lives, commutes, or travels to an area with Zika should use condoms consistently and correctly every time they have sex or not have sex during pregnancy. 15
Men and women with possible Zika exposure Possible exposure via recent travel or sex without a condom with a partner infected with Zika Women Men Use condoms for at least 8 weeks after travel or start of symptoms (or diagnosis) Use condoms for at least 6 months after travel or start of symptoms (or diagnosis) Men/women who live, commute or travel to areas with Zika Positive Zika test Women Wait at least 8 weeks after symptoms start Men Wait at least 6 months after symptoms start No testing performed or negative test Talk with doctor/healthcare provider 16
PRECONCEPTION GUIDANCE Couples interested in conceiving who DO NOT reside in an area with active Zika virus transmission For women with possible exposure to Zika virus» Discuss signs and symptoms and potential adverse outcomes associated with Zika.» Wait at least 8 weeks after last possible exposure to or symptoms started before trying to conceive.» During that time, use condoms every time during sex or do not have sex. 17
Couples interested in conceiving who DO NOT reside in an area with active Zika virus transmission For men with possible exposure to Zika virus» Wait at least 6 months after last possible exposure to Zika or symptoms started before trying to conceive.» During that time, use condoms every time during sex or do not have sex to protect partner. Couples interested in conceiving who reside in an area with active Zika virus transmission Women and men interested in conceiving should talk with their HCPs. Factors that may aid in decision-making» Reproductive life plan.» Environmental risk of exposure.» Personal measures to prevent mosquito bites.» Personal measures to prevent sexual transmission.» Education about Zika virus infection in pregnancy.» Risks and benefits of pregnancy at this time. 18
WHAT TO TELL PATIENTS ABOUT ZIKA Pregnant women Should not travel to areas with Zika. Consider postponing nonessential travel to areas where Zika is endemic. If travel is unavoidable,» pregnant women should protect themselves from mosquito bites and» take steps to prevent sexual transmission during/after travel. 19
Treating patients who test positive There is no vaccine or medicine for Zika. Treat the symptoms of Zika» Rest» Drink fluids to prevent dehydration» Take acetaminophen (Tylenol ) to reduce fever and pain. Patients who have Zika Protect from mosquito bites during the first week of illness, when Zika virus can be found in blood. Virus can be passed from an infected person to a mosquito through bites. Infected mosquitos can spread the virus to others. 20
WHAT TO TELL PATIENTS ABOUT MOSQUITO BITE PROTECTION Mosquito bite protection Wear long-sleeved shirts and long pants. Stay/sleep in places with air conditioning and window and door screens to keep mosquitoes outside. Take steps to control mosquitoes inside and outside your home. Sleep under a mosquito bed net if air conditioned or screened rooms are not available or if sleeping outdoors. 21
Mosquito bite protection Use Environmental Protection Agency (EPA)-registered insect repellents with one of the following active ingredients: DEET, picaridin, IR3535, oil of lemon eucalyptus or para-menthane-diol, or 2-undecanone. Always follow the product label instructions. Do not spray repellent on the skin under clothing. If you are also using sunscreen, apply sunscreen before applying insect repellent. Mosquito bite protection Do not use insect repellent on babies younger than 2 months old. Do not use products containing oil of lemon eucalyptus or para-menthane-diol on children younger than 3 years old. Dress children in clothing that covers arms and legs. Do not apply insect repellent onto a child s hands, eyes, mouth, and cut or irritated skin. 22
11/12/2016 45 A Healthy Pima County. Every one. Every where. Every day. 11/12/2016 46 What is Pima County Doing? Closely coordinating with ADHS and CDC Tracking endemic transmission in Mexico Communicating closely with Maternal Fetal Medicine providers Coordinating with health care institutions Mosquito surveillance and control Tracking of vector related human disease Public outreach and education A Healthy Pima County. Every one. Every where. Every day. 23
11/12/2016 47 Government Partners Arizona Department of Health Services Regular communication with relevant components, ASL, Epi, Preparedness Weekly Border Surveillance Report (infectious disease) Coordinate bi national investigations for vector borne diseases Customs & Border Protection Coordinate vector trapping around Tucson Sector processing/intake areas Quarterly meetings to review communicable disease plans and provide infection prevention education A Healthy Pima County. Every one. Every where. Every day. 11/12/2016 48 Community Partners Arizona Poison Center Mosquito prevention education & communications Serve as community/healthcare provider point of contact/data collection for Zika information & risk assessment Follow up with providers and clients as necessary Social Media images to promote call center Zika webpage A Healthy Pima County. Every one. Every where. Every day. 24
11/12/2016 49 Zika Prevention Outreach Informational cards A Healthy Pima County. Every one. Every where. Every day. 11/12/2016 50 Zika Prevention Outreach Social media Instagram Keep 'em out! Add checking and fixing your screens to your to-do" list this weekend!! http://ow.ly/qu69303irto Twitter Traveling soon? Remember to protect yourself from mosquito bites! Check here before you go http://ow.ly/yrym303ir5s Facebook Traveling soon? No matter your destination, protect yourself from mosquito bites! Stay healthy while on the move - visit CDC's traveler resource page: http://ow.ly/yrym303ir5s A Healthy Pima County. Every one. Every where. Every day. 25
11/12/2016 51 Community Outreach Magnets A Healthy Pima County. Every one. Every where. Every day. 11/12/2016 52 Questions? A Healthy Pima County. Every one. Every where. Every day. 26
Additional resources http://www.cdc.gov/zika/index.html http://www.cdc.gov/zika/hc-providers/index.html http://www.cdc.gov/zika/hc-providers/index.html 27