Delaware Health Alert Network #361
April 7, 2016 3:43 pm
Health
Advisory
UPDATED GUIDANCE TO HEALTH CARE PROVIDERS ON ZIKA VIRUS DISEASE
Contents:
Summary
Background
Current situation of Zika in U.S. and in DE
Transmission
Clinical features, differential diagnoses and complications
Reporting cases of Zika
Laboratory testing
Management of Zika Virus infection
Patient counseling
Prevention of Zika virus infection
Zika pregnancy registry
Contacting the Division of Public Health
Additional information
The Delaware Division of Public Health (DPH) is issuing this health alert to provide updated information to health care providers
regarding the ongoing Zika virus epidemic
Summary
The Zika virus outbreak in the Americas that started in early 2015 continues to evolve. More information about the virus, the nature of
the infection, and the distribution of the disease is emerging on a continual basis. As more is learned, the Centers for Disease Control
and Prevention (CDC), state and local health departments will continue to release updated guidance to educate the public and health care
providers on measures to take to prevent Zika virus transmission, as well as updated information about the health effects that result
from infection with the virus.
Background
Zika virus is an arbovirus (virus spread by arthropods) that is a member of the flavivirus family along with other viruses including
yellow fever, West Nile, dengue and Saint Louis encephalitis viruses. First isolated in 1947, it did not appear in the Americas until
early 2014 when it was identified on Easter Island (Chile). By early 2015, an outbreak of the virus began in Brazil. As of March, 31,
2016, locally acquired cases of Zika virus have been reported from 33 countries and territories in the Americas. Previously thought to be
a generally mild illness, the ongoing epidemic has highlighted serious complications, from the infection that were previously
unidentified or unreported (particularly in infants whose mothers were infected with the virus while pregnant).
Current situation of Zika Virus infection in U.S. and in DE
As of March 30, the U.S. has 312 reported travel-associated cases of Zika from 34 states, including three confirmed cases in
Delaware. None of the three Delaware cases were pregnant and all acquired the disease due to a mosquito bite while traveling abroad.
Sexual transmission of Zika has been documented in six U.S. states so far. No sexual transmission has been reported in Delaware. Apart
from Puerto Rico, American Samoa, and the U.S. Virgin Islands where there is ongoing transmission, there have (as of March 31) been no
cases of mosquito-borne Zika virus infection in the U.S.
Transmission
Transmission of Zika virus is primarily through the bites of infected Aedes mosquitos with the primary vector being Aedes
aegypti (also known as the yellow fever mosquito). Aedes aegypti is also an important vector for dengue virus and
chikungunya virus. Isolation of the virus in, or transmission by other Aedes species in natural or laboratory settings has been reported.
Of particular interest is Aedes albopictus (Asian Tiger Mosquito) given its relative abundance in the continental U.S.,
including Delaware.
The sexual route of transmission for the Zika virus has been recently described (2008) with several Zika virus infections in the current
epidemic also being linked to sexual transmission. As of March 31, all cases of sexual transmission of Zika were from an infected male to
a female. It is yet to be determined if Zika can be transmitted from a female to her sexual partners. It has also not been established
which forms of sex (vaginal, anal or oral) pose the highest risk for sexual transmission of Zika virus. The CDC is currently conducting
studies to determine how long Zika persists in the semen of infected men.
Mother to child transmission of Zika virus during pregnancy and/or child birth is a third mode of transmission. Zika infection during
pregnancy has been shown to result in poor pregnancy outcomes including miscarriage, stillbirths, and fetal growth retardation.
Particularly concerning are the severe neurologic consequences including microcephaly that are associated with Zika infection in
pregnancy. It remains unclear during which trimester of pregnancy the risk of transmission is highest. Studies are also ongoing to
determine the impact of infection at different stages of pregnancy and how frequently an infected mother will transmit the virus to her
unborn child.
Transmission of Zika virus through the inadvertent transfusion of infected blood is yet another means by which the virus can spread. New
guidance from the federal government on blood transfusions is expected soon.
Clinical features, differential diagnoses and complications
Most Zika virus infections are asymptomatic. About one in five people infected with the virus develop the disease and symptoms are
generally mild comprising any combination of fever, rash, joint pain, or conjunctivitis. Symptoms typically begin after an incubation
period of a few days to a week. In most cases, symptoms resolve within a few days to a week.
Differential diagnoses for the characteristic symptoms of Zika are myriad and (given the relevant travel or exposure history) might
include Leptospirosis, malaria, Rickettsia, group A Streptococcus, rubella, measles, parvovirus, enterovirus, adenovirus, dengue fever,
and chikungunya (or other alpha viruses).
The current Zika epidemic has brought to light serious consequences of what was previously thought to be a benign disease. Poor pregnancy
outcomes (stillbirth, miscarriages) and microcephaly have been linked to Zika virus infection. There is also accumulating evidence
that implicates the virus in a spectrum of neurologic syndromes in adult/adolescents including Guillaine-Barre syndrome and acute
myelitis amongst others. Long term consequences of Zika virus infection are yet to be determined.
Reporting cases of Zika
Zika virus infection is a reportable disease in Delaware. It is important to identify and report cases or suspected cases of Zika virus
infection both for the benefit of the individual patient and for the public’s health. It is also important to report pregnant women
who have had potential exposures to Zika virus. Exposure of a pregnant woman would include travel to areas with ongoing Zika virus
infection at any time during her pregnancy or eight weeks prior to conception (See http://www.cdc.gov/zika/geo/ for an updated listing of affected areas). Unprotected sex, during her
pregnancy with a man known to have Zika virus infection would also constitute exposure for a pregnant woman. Such individuals should be
referred for laboratory testing (See DPH contact information below).
Although most non-pregnant people do not have serious consequences from Zika virus infection, it is also important to refer individuals
with relevant travel and exposure AND consistent symptoms for testing. This referral will allow the Division of Public Health and the
Department of Natural Resources and Environmental Control (DNREC) to apply measures to help protect the public’s health. Report
these cases by using the phone numbers and email addresses listed under “Contacting the Division of Public Health.”
Laboratory testing
The Delaware Division of Public Health Laboratory (DPHL) is able to perform testing for Zika virus infection. The specific type of
testing depends on presence or absence of symptoms and how long after symptom onset the test is being performed.
Testing is done by Polymerase Chain Reaction (PCR) and/or IgM ELISA (Serology) performed on serum and urine specimens. As of March 31,
DPHL is doing PCR testing in-house and sending specimens to the CDC for IgM ELISA. It is expected that DPHL will be able to add on Zika
IgM ELISA in the next few weeks.
Priority for testing is given to pregnant women. Thus, testing of non-pregnant individuals will be limited to only those who have
symptoms consistent with Zika virus infection PLUS a history of travel to areas with ongoing transmission of Zika virus.
Testing will be performed on pregnant women who have concerning exposures (consistent travel history or unprotected sex with a male Zika
case) regardless of whether or not the pregnant woman has symptoms. This includes women who traveled to affected areas within eight weeks
prior to becoming pregnant (or six weeks before last menstrual period).
It is important that such pregnant women be referred to DPH for testing as soon as possible after their exposure/travel as testing can
only be offered during the two to 12 weeks after they return from travel for asymptomatic patients. Those presenting with symptomatic
disease should be tested as soon as possible (preferably within the first week of illness).
Contact the Delaware Division of Public Health to arrange for testing of patients (See contact listed under “Contacting
DPH”). When specimens are submitted to the DPHL, specimens will also be tested for dengue and chikungunya viruses.
Management of Zika virus infection
There is currently no vaccine to prevent, or antiviral to treat Zika virus. Patients should be managed symptomatically. Given the
significant overlap in geography and symptomatology with dengue virus infection, aspirin and non-steroidal anti-inflammatory drugs
(NSAIDs) should be avoided until dengue is ruled out in order to avoid potential hemorrhagic complications that might ensue if the
patient has dengue.
Patient counseling
- Before travel or exposure
Health care providers should discuss reproductive life plans, including pregnancy intention and timing, with women of reproductive age
in the context of the potential risks associated with Zika virus infection.Pregnant women and their male sexual partners should be counseled to defer travel to areas with ongoing Zika virus transmission. See
http://wwwnc.cdc.gov/travel/page/zika-information for updated travel
advisory relevant for Zika virus. Where postponement of travel is not possible, patients should be counseled to take strict measures to
avoid mosquito bites and unprotected sexual encounters while in those areas with ongoing transmission. Mosquito avoidance measures are
listed under “Prevention of Zika virus infection” below.Pregnant women whose male sexual partners live in or have traveled to areas with ongoing transmission of Zika virus should be counseled
to use condoms correctly and consistently for the duration of the pregnancy or to avoid sex with the returned traveler for the duration
of the pregnancy.Providers whose pregnant patients travel to affected areas should advise patients to notify them upon their return. Such patients
should thereafter be referred to DPH’s Zika pregnancy registry (See “Zika pregnancy registry” below). Also see
“Additional information” below for patient education materials and links to DPH’s easy to understand Zika website - Following travel, exposure or infection
Because a lot is still unknown about the pathophysiology and persistence of Zika virus in various tissues and bodily fluids, the CDC
recommends that women who desire to conceive be counseled to wait at least eight weeks after exposure (or after symptoms first appear)
prior to attempting to conceive. Men who have been diagnosed with Zika virus or have consistent symptoms should be advised to wait at
least six months after symptoms first appeared before having unprotected sex. (See “Patient counseling: Before travel or
exposure” above for recommendations for pregnant partners of infected men).Pregnant women who return from areas with ongoing transmission should be referred to DPH’s Zika pregnancy registry (See
“Zika Pregnancy registry” below).Counsel patients with confirmed Zika virus infection to practice mosquito avoidance measures for the first week of illness to prevent
transmission of the infection to others. (See “Prevention of Zika virus infection” below for list of mosquito avoidance
measures.)Because the list of emerging infectious diseases continues to expand, health care providers should ask all their patients about recent
travel. This will help providers to identify patients who might be at risk for an emerging or re-emerging infectious disease
(including, but not limited to Zika virus infection). To screen patients for travel-related and other emerging infectious diseases,
health care providers should consider using the updated DPH travel and emerging disease screening tool at:
http://www.dhss.delaware.gov/dph/php/files/emergingandtravelrelatedinfdiseasescreeningtool.pdf
Prevention of Zika virus infection
The primary means of preventing Zika virus infection is by mosquito avoidance including personal protective measures and reduction of
mosquito breeding habitats.
Although as of April 5, there have been no locally transmitted cases of Zika virus infection in DE, as the weather warms up, both
approaches will become important for the prevention of not only Zika virus but also other mosquito-borne illnesses including dengue,
chikungunya, West Nile virus and Saint Louis encephalitis.
It is also important to counsel pregnant women to avoid travel to areas with ongoing transmission if at all possible and to avoid
unprotected sex with men who have traveled to such areas (See “Patient Counseling” above).
- Counsel patients on the following mosquito avoidance measures:
- Wearing long-sleeved shirts and long pants
- Staying in places with air conditioning or that use window and door screens to keep mosquitoes outside
- Sleeping under a mosquito bed net while overseas or outside in areas with mosquitos
- Use of Environmental Protection Agency (EPA) registered insect repellents. When used as directed, EPA-registered insect
repellents are proven safe and effective, even for pregnant and breast-feeding women - Treating clothing with permethrin or purchase of permethrin-treated items
- Counsel patients on the following measures to reduce mosquito breeding habitats around their homes:
- Eliminate any unneeded outside standing water that would last four or more days if not dumped or drained. There are myriad
water-holding objects or structures around a residence that would meet these criteria. People should do the following:- Clean debris from clogged rain gutters
- Dump water from corrugated downspout extenders; frequently change water in birdbaths, drain unused or abandoned swimming
pools (whether in-ground or above ground or kiddie wading pools) - Empty standing water from containers such as discarded or used tires, old cans or buckets, flower pot liners,
children’s toys, unprotected water cisterns, upright wheelbarrows, uncovered trash cans (or upturned trash can lids on the
ground), open or lidless trash dumpsters, water in still plugged or undrained boat bottoms, sags in tarps covering boats or ATVs,
etc.
- Prevent accumulation of such outside water in the first place.
- Eliminate any unneeded outside standing water that would last four or more days if not dumped or drained. There are myriad
- Standard precautions during healthcare delivery
It is important that health care providers adhere to standard precautions during all health care delivery. Health care personnel should
assess the potential for exposure to potentially infectious material and protect themselves accordingly, based on the level of clinical
interaction with the patient. In addition, health care providers should use soap and water or alcohol-based products (gels, rinses,
foams), at a minimum, before and after a patient contact and after removing any personal protective equipment used, including gloves.
See “Additional information” below for information specific to delivery of pregnant women.
Zika pregnancy registry
To understand more about Zika virus infection, CDC established the U.S. Zika Pregnancy Registry and is collaborating with state, tribal,
local, and territorial health departments (including Delaware DPH) to collect information about Zika virus infection during pregnancy and
about congenital Zika virus infection. The data collected through this registry will be used to update recommendations for clinical care,
to plan for services for pregnant women and families affected by Zika virus, and to improve prevention of Zika virus infection during
pregnancy.
Contact the Division of Public Health to enroll patients in the Zika pregnancy registry (see DPH contact details below)
Contacting the Division of Public Health
Contact DPH Office of Infectious Disease Epidemiology at 888-295-5156 or 302-744-4990 for guidance with regard to specimen collection,
coordination of testing, and further information and to report suspected cases of Zika virus infection or exposure of pregnant women.
Additional information
- More information for health care providers
- Preventing Transmission of Zika Virus in Labor and Delivery Settings Through Implementation of Standard Precautions http://www.cdc.gov/mmwr/volumes/65/wr/mm6511e3.htm
- Update: Interim Guidance for Health Care
Providers Caring for Women of Reproductive Age with Possible Zika Virus Exposure — United States, 2016 http://www.cdc.gov/mmwr/volumes/65/wr/mm6512e2er.htm?s_cid=mm6512e2er_e - Update: Interim Guidance for Prevention of Sexual Transmission of Zika Virushttp://www.cdc.gov/mmwr/volumes/65/wr/mm6512e3er.htm?s_cid=mm6512e3er_e
- For the latest Centers for Disease Control and Prevention (CDC) list of impacted countries, visit: http://wwwnc.cdc.gov/travel/notices
- Department of Natural Resources and Environmental Control mosquito control: http://www.dnrec.delaware.gov/fw/mosquito/Pages/MC-Diseases.aspx
- Patient education materials for printing and posting
- Division of Public Health Zika page: http://dhss.delaware.gov/dph/zika.html
- Educational flyer for pregnant women in:
- Facts and information on Zika and mosquito control:
- Zika information in Spanish (CDC link): http://www.cdc.gov/spanish/mediosdecomunicacion/comunicados/d_recomendaciones_viajeros_virus_del_zika_011516.html
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