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Tufts University / Tufts Medical Center Exposure Response Plan for the Laboratory Handling of Zika virus BACKGROUND INFORMATION: The agent: Zika virus is a member of the flaviviridae family and genus Flavivirus. It is an enveloped, icosahedral virus containing ssRNA + sense. It is related to Dengue virus and West Nile Virus. Clinical Presentation: Zika virus disease is characterized by mild headache, rash, fever, malaise, conjunctivitis and joint pain. The incubation period is unknown but estimated to be a few days to a week. Zika is generally a mild disease with 80% of infected persons remaining asymptomatic. Symptoms last from 2-7 days. Recovery is thought to be complete in the overwhelming majority, however there is a suggestion of connection with Guillain-Barre Syndrome. After someone has been infected, Zika virus can be present in blood and body fluids, including semen, urine, and saliva. Teratogenic effects: Risks associated with fetal exposure to Zika virus include loss of pregnancy, microcephaly, and brain, hearing, and/or vision abnormalities. At this time, the magnitude of risk is not able to be quantified due to limited data. It not entirely clear at what time(s) in fetal development that exposure to Zika virus presents the highest risk, but some evidence suggests highest risk exists during the first trimester. The mechanism(s) by which Zika virus causes these problems remains unknown at the present time. Natural and other routes of exposure: Transmission typically occurs via mosquito bite. The two known species responsible for Zika virus transmission are the Aedes albopictus, known as the Asian Tiger mosquito, and the Aedes aegypti species. The latter species also transmits dengue fever and chikungunya. Aside from mosquito bites, Zika virus can be transmitted via sexual contact, and transplacentally from mother-to-fetus. Exposure to infected blood has also resulted in transmission. Zika virus transmission has been reported following blood transfusion, and was recently transmitted to a researcher via needlestick. Infectious Dose: Unknown HEALTH SCREENING REQUIREMENTS FOR LAB WORKERS: Prior to initiation of work with Zika virus in the laboratory, workers must have a health screen/questionnaire and receive reproductive counseling. At this screening, employees will be educated on the risks of working with Zika virus, and symptoms of Zika virus disease by Occupational Health Nurse or Physician. Employees will meet privately with the clinician, and have opportunity to ask questions. HOW TO HANDLE EXPOSURES: Before an Exposure Incident Occurs: There is no prophylaxis, treatment or vaccine to protect against Zika virus infection. Therefore, preventive measures are recommended. Recommendations for Laboratory Workers: PPE: At a minimum, lab coat or gown should be worn along with gloves and safety glasses. For procedures with the potential for splashes or spills, a surgical mask or face shield should be worn. Although Zika virus is designated as a risk group 2 agent, some procedures may require biosafety level 3 precautions including respiratory protection, depending on the nature of the work being done. Sharps: Strict adherence to safe sharps usage is recommended. Safety sharps should be used whenever possible; alternatively syringes with integral needles or luer-lock needles may be used. Needles should never be re-used or re-capped. Training: Workers should be familiar with the laboratory procedures and practices involving this agent prior to working unsupervised. Exposure Incidents: Exposure to Zika virus in the laboratory setting may occur in a number of ways. The highest risk of illness is following exposure to Zika virus via needlestick. Exposure to Zika virus may also occur via ingestion (mouth) contact with mucous membranes (mouth, nose, and eyes), absorption through nonintact skin (i.e. skin wound) and through inhalation (lungs). The risk of infection following these routes of exposure is thought to be low, with no known instances occurring. Post-exposure Actions: Immediate Actions: o Needlestick or scratch: Wash the area with soap and running water for 15 minutes. Do not apply bleach, alcohol or other disinfectant to the skin. Hypodermic needle or contaminated sharps injection into blood will have fastest effect. o Mucous membranes (eye, nose, mouth): If contaminated material is splashed or sprayed into the face contaminating the eyes, nose or mouth: flush the eyes for 10-15 minutes, rinse mouth out with clean water and be sure not to swallow, and wash down face being sure that the nasal cavities have been rinsed as much as possible. o Inhalation: If contaminated materials are aerosolized outside of primary containment and potentially inhaled, rinse mouth twice expelling the rinsate. Do not swallow. o Contact with intact skin and clothing: Remove contaminated clothing using gloves either discard as biological or medical waste or autoclave prior to laundering and re-use. Wash contaminated skin with soap and water. Medical Evaluation and Follow-up: o You must be seen by a qualified medical professional following exposure. o For incidents involving major medical emergencies, activate Emergency Medical Services: At TU, call the University Police at x66911 At TMC, call Public Safety at x65100 o For all other incidents: Following immediate actions, contact the campus occupational health services and arrange for medical diagnosis and treatment. Boston Tufts MC Employee Health Clinic: 617-636-5480 Grafton TCSVM Occupational Medical Clinic: 508-887-4241 (limited hours) or 866-360-8100 (on-call physician for Exposure Response Call Center) Medford Mt. Auburn Occupational Health Services: 617-354-0546 Reporting of Exposure Incidents: All exposure incidents must be reported within 24 hours to the Principal Investigator and the Biosafety Office. The Biosafety Office may be reached by phone (617-636-3569) or email ([email protected]). Post-Exposure Treatment: There is no vaccine or specific treatment. Patients who develop Zika virus disease should rest, stay hydrated, and use acetaminophen (Tylenol) for fever and pain. An antihistamine, diphenhydramine (Benadryl), can be taken for rash symptoms. Avoid aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen. REFERENCES: CDC, Zika virus web site: http://www.cdc.gov/zika/index.html CDC, Interim Guidelines for Pregnant Women: http://www.cdc.gov/mmwr/volumes/65/wr/mm6502e1er.htm?s_cid=mm6502e1er CDC, travel notices: http://wwwnc.cdc.gov/travel/notices/ Dick GW, Kitchen SF, Haddow AJ. Zika virus. I. Isolations and serological specificity. Trans R Soc Trop Med Hyg. 1952 Sep;46(5):509-20. Fauci AS, Morens DM. Zika Virus in the Americas - Yet Another Arbovirus Threat. N Engl J Med. 2016 Jan 13. Hayes EB. Zika virus outside Africa. Emerg Infect Dis. 2009 Sep;15(9):1347-50. Schuler-Faccini L, Ribeiro EM, Feitosa IM, Horovitz DD, Cavalcanti DP, Pessoa A, Doriqui MJ, Neri JI, Neto JM, Wanderley HY, Cernach M, El-Husny AS, Pone MV, Serao CL, Sanseverino MT; Brazilian Medical Genetics Society–Zika Embryopathy Task Force. Possible Association Between Zika Virus Infection and Microcephaly - Brazil, 2015. MMWR. 2016 Jan 29;65(3):59-62. Foy BD, Kobylinski KC, Chilson Foy JL, Blitvich BJ, Travassos da Rosa A, Haddow AD, Lanciotti RS, Tesh RB. Probable non-vector-borne transmission of Zika virus, Colorado, USA. Emerg Infect Dis. 2011 May;17(5):880-2. MMWR, Possible Association Between Zika Virus Infection and Microcephaly Brazil, 2015. January 29, 2016/ 65(3);59-62.