Health

Update

ZIKA VIRUS DISEASE SHOULD BE CONSIDERED IN DIFFERENTIAL DIAGNOSIS FOR PERSONS WITH COMPATIBLE
SYMPTOMS EVEN IN ABSENCE OF TRAVEL

The Delaware Division of Public Health (DPH) is issuing this update to advise Delaware health care providers of the need to consider Zika
in the differential diagnosis for patients presenting with compatible symptoms even if the patients deny history of travel outside of the
local area.

Summary

As of September 6, 2016, there have been no documented cases of local Zika transmission either through mosquitoes or sexual contact in
the state of Delaware. However, there have been multiple reports of local transmission (through mosquitoes) in Florida and at least one
report (in Maryland) of transmission through sexual contact in individuals with no history of travel.

Background

On August 26, 2016, the Maryland Department of Health reported Zika virus disease in a non-pregnant woman who reported to her physician
with symptoms compatible with Zika virus infection but who had no history of travel to areas with ongoing Zika virus transmission.
Further questioning revealed that her sexual partner had recently returned from travel to Dominican Republic (where there is ongoing
transmission of Zika) but had himself had no symptoms of Zika. This case represents the first known transmission of Zika from a person
without Zika virus symptoms in which sexual contact was established as the most likely means of transmission.

Recommendations

Current recommendations for Zika virus testing are primarily based on testing SYMPTOMATIC returned travelers and their sexual partners
who develop symptoms as well as pregnant women (symptomatic or not) who return from travel to affected areas. These recommendations are
still in place

In addition, given the new information about the possibility of sexual transmission of Zika from non-symptomatic returned travelers,
providers should maintain a high index of suspicion and consider testing non-travelers who develop Zika symptoms (including fever,
arthralgia, rash, and conjunctivitis) and for whom there is no more plausible explanation for their symptoms. At the very least,
providers should question such individuals to see if they have had sexual exposure to an individual who recently returned from areas with
ongoing Zika transmission.

Providers should continue to counsel their patients (particularly pregnant women) on the importance of using barrier methods such as
condoms to prevent sexual acquisition of Zika from individuals with history of recent travel to areas with widespread Zika transmission.
Pregnant women whose sexual partners return from such areas should use barrier protection for the duration of their pregnancy or
otherwise abstain from sex for the duration of their pregnancy.

Laboratory Testing for Zika

Serum and urine PCR for Zika virus are available through the DPH Laboratory as well as through several commercial laboratories. Serology
testing (Zika IgM antibody capture Enzyme-linked immunosorbent assay: Zika MAC-ELISA) is offered through the DPH Laboratory and recently
has become available in some commercial laboratories.

PCR testing is indicated for serum samples collected fewer than seven days and urine samples collected fewer than 14 days after symptom
onset (or last possible exposure if no symptoms). While a positive PCR test is confirmatory of Zika virus infection, a negative PCR test
result does not exclude Zika virus infection and serologic testing by ELISA for Zika IgM antibody should be completed. Zika IgM antibody
ELISA is indicated for the diagnosis of Zika two to 12 weeks from the onset of symptoms (or from the last possible exposure).

Any provider diagnosing Zika in a patient or who wishes to arrange for testing through the DPH lab should contact DPH at the number
below.

For a comprehensive list of measures and an updated list of prevention efforts, visit http://dhss.delaware.gov/dph/zika.html

Contacting DPH

Providers are asked to call DPH for any guidance needed in selecting the appropriate test to order for their patient or to arrange for
Zika virus testing, coordinate specimen collection or to report any suspect case of Zika virus infection or pregnant woman with potential
exposure to Zika virus. Zika is a reportable disease in Delaware.

Contact DPH at 888-295-5156 or 302-744-4990

Additional Information

1. Maryland reports likely sexual transmission of Zika in a person with no travel history http://www.cdc.gov/mmwr/volumes/65/wr/mm6534e2.htm
2. More information for health care providers:
   • Update: Interim Guidance for Health Care Providers Caring for Pregnant Women with Possible Zika Virus Exposure — United
     States, July 2016 http://www.cdc.gov/mmwr/volumes/65/wr/mm6529e1.htm?s_cid=mm6529e1_w
   • Update: Interim Guidance for Prevention of Sexual Transmission of Zika Virus http://www.cdc.gov/mmwr/volumes/65/wr/mm6529e2.htm?s_cid=mm6529e2_w
   • 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
3. 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:
     • English: http://www.dhss.delaware.gov/dph/files/zikaflyerforpregnantwomen.pdf
     • Spanish: http://www.dhss.delaware.gov/dph/files/zikaflyerforpregnantwomensp.pdf
     • Haitian Creole: http://www.dhss.delaware.gov/dph/files/zikaflyerforpregnantwomenhc.pdf
   • Facts and information on Zika and mosquito control:
     • English: http://www.dhss.delaware.gov/dph/files/zikafaq.pdf
     • Spanish: http://www.dhss.delaware.gov/dph/files/zikafaqsp.pdf
     • Haitian Creole: http://www.dhss.delaware.gov/dph/files/zikafaqhc.pdf

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