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ZIKA UPDATE

Clinical Aspects
PQCNC 11/9/2016

Katie Davidson MD
MFM with MAHEC

Adapted from:

Relavent routes of transmission


Maternal-fetal
Sexual
Breastfeeding?

Infection characteristics
Yap Island serosurvey 2007
Infection rate: 73%
Symptomatic attack among infected: 18%

Incubation: 314 days


Viremia: 3-7 days
Evidence that pregnant women, semen
and urine may have virus longer

3 14 days

Clinical disease course and outcomes

Clinical illness is usually mild.


Symptoms last several days to a week.
Severe disease requiring hospitalization is
uncommon.
Fatalities are rare.
Research suggests that Guillain-Barr
syndrome (GBS) is strongly associated with
Zika; however only a small proportion of
people with recent Zika infection get GBS.

Reported clinical symptoms among confirmed Zika virus disease cases

Yap Island, 2007


Duffy M. N Engl J Med 2009

Clinical features: Zika virus compared to 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)

Treating affected patients


Symptomatic relief
Rest
Drink fluids to prevent dehydration
Tylenol for fever and pain

Who to test for Zika

CDC does not recommend


tes-ng for asymptoma-c
men, children, and women
who are not pregnant.

Testing & Reporting

Review up to date recommendations for testing


http://www.cdc.gov/zika/hc-providers/types-of-tests.html
Details of current understanding/recommendations on next few slides

Consult with your health department for assistance and reporting purposes
US Zika Pregnancy Registry (USZPR)
CDC run 24/7 consultation service for healthcare providers of pregnant women
800-CDC-INFO (800-232-4636),or email ZIKAMCH@cdc.gov.

Testing guidance: Pregnant women with possible Zika exposure

Diagnostic testing for Zika virus

During first 2 weeks after the start of illness, Zika virus


infection can often be diagnosed by performing real-time
reverse transcriptase polymerase chain reaction (rRTPCR) on serum and urine.
Serology assays can also be used to detect Zika virusspecific 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.
Immunohistochemical (IHC) staining for viral antigens or
RT-PCR on fixed tissues.

Serology cross-reactions with other flaviviruses

Zika virus serology (IgM) can be positive due to


antibodies against related flaviviruses (e.g., dengue and
yellow fever viruses).
As viremia decreases over time, a negative rRT-PCR
collected after symptom onset does not preclude Zika; in
this case, serologic testing should be performed.
Neutralizing antibody testing may discriminate between
cross-reacting antibodies in primary flavivirus infections.
Difficult to distinguish infecting virus in people previously
infected with or vaccinated against a related flavivirus.

Zika and pregnancy outcomes

Zika virus can pass from a pregnant woman


to her fetus during pregnancy or around the
time of birth.
Unknown - What rate?

Zika infection in pregnancy is a cause of


microcephaly and other severe brain
defects. Other problems include
Miscarriage, stillbirth, and birth defects
including absent or poorly developed brain
structures, defects of the eye, hearing
deficits, limb abnormalities, and impaired
growth.

Case definition of microcephaly


Definition of congenital microcephaly
Head circumference (HC) at birth is less than the
3rd percentile for gestational age and sex.

Alternative definition:
>3SD (<0.5%) or >2SD (<2.5%) with abnormal
intracranial anatomy
Baby with microcephaly

Still so many questions

Surprising clusters
Outbreaks for years why surge in microcephaly cases in Brazil ~1year ago?
~90% of the confirmed cases of affected babies are from small NE region

Other factors at play?


Socio-economic factors? young, single, black, poor, rural
Co-infections? dengue and chikungunya, bovine viral diarrhoea virus (BVDV)
Low yellow fever vaccination rates

Nature 7/25/16

US

139 locally acquired cases (FL)


~4000 travel associated cases
Now 30 aected infants/s-llbirths
WHO situation report, 11/3/16

Recommendations for pregnant women

Do not travel to areas with Zika


If they must travel to areas with
Zika, employ protection from
mosquito bites (DEET, picardin,
clothing, etc) and sexual
transmission (condoms)

Clinical management of a pregnant woman with suspected Zika virus infection

Pediatric evaluation and follow up tools

Download at: http://www.cdc.gov/


zika/pdfs/pediatric-evaluationfollow-up-tool.pdf

About sexual transmission

Zika can be passed through sex from a


person who has Zika to sex partners.
Possible before, during, after symptoms
or with asymptomatic infection
Zika virus cultured from semen up to 69
days after symptom onset.

We dont know:
How common sexual transmission is
If sexual transmission carries the same
or different risks to pregnant women

Men and women with possible Zika exposure

Possible exposure via recent travel or sex without a


condom with a partner infected with Zika
Women

Use condoms for at


least 8 weeks aTer
travel or start of
symptoms (or
diagnosis)

Men

Use condoms for at


least 6 months aTer
travel or start of
symptoms (or
diagnosis)

Couples interested in conceiving who reside


in an area with active Zika virus transmission

Discuss with 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

Additional resources

http://www.cdc.gov/zika/index.html
http://www.cdc.gov/zika/hc-providers/index.html
http://www.acog.org/zika
https://www.smfm.org/links/zika
http://www.who.int/emergencies/zika-virus/situation-report/en/

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