Download Zika update from ISDH

Zika Virus Response in
Indiana
EMILY POT TS, MPH, INDIANA STATE DEPARTMENT OF HEALTH (ISDH)
Epidemiology Resource Center “Zika
Team”
Emily Potts – Zika Virus Clinical Coordinator
◦ USZPR, testing authorizations, coordination of specimens at time of delivery
Taryn Stevens – Vector-Borne Epidemiologist
◦ SME, case investigations
Jen Brown – State Public Health Veterinarian
◦ Director, Zoonotic and Vector-Borne Epidemiology
Today’s Presentation
Zika: Quick Overview of the Basics
CDC Guidance
◦ Pregnancy
◦ Zika in Healthcare Settings
◦ Testing for Zika
Zika Virus Cases and Testing in Indiana
Zika: An Overview of the Basics
Zika virus
Single-stranded RNA virus
Closely related to dengue, yellow fever, Japanese
encephalitis, and West Nile Virus
Genus Flavivirus, Family Flaviviridae
Primarily transmitted by two Aedes species
mosquitoes
◦ Aedes aegypti and Aedes albopictus mosquitoes
Additional modes of transmission
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Intrauterine and perinatal (Mother to Fetus)
Sexual
Laboratory exposure
Probably blood transfusion
Zika virus. Photo: CDC.
Current Zika virus transmission
63 countries and territories
worldwide, including 43
countries and territories in the
Americas reporting active Zika
virus transmission.
Countries with endemic Zika
virus pose a risk.
CDC. Updated March 16, 2017.
Clinical Presentation
Clinical illness usually mild
Most common symptoms
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Fever
Rash
Joint pain
Conjunctivitis
Symptoms last several days to a week
Severe disease uncommon
Fatalities are rare
Once infected, a person is likely to be protected
from future infections
Zika in Fetal Tissues
Zika virus has been shown to be present in fetal
tissue
Evidence of Zika virus has been detected in
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Amniotic fluid
Placenta
Fetal brain tissue
Products of conception
Zika virus has been found to continue to replicate
in infants' brains after birth (Bhatnagar et al.,
2017)
Immunohistochemical staining of Zika virus antigen (red stain) in fetal brain
tissue. This staining is present in the same areas where neuronal cell
death/necrosis was identified by microscopic review of tissue morphology.
Bhatnagar J, Rabeneck DB, Martines RB,Reagan-Steiner S, Ermias Y, Estetter LBC, et al. Zika virus RNA replication and persistence in brain and placental tissue. Emerg
Infect Dis. 2017 Mar [Epub ahead of print]. Reference/attribution for image: Ritter JM, Martines RB, Zaki SR. Zika Virus: Pathology From the Pandemic. Arch Pathol Lab
Med. 2016 Oct 5. [Epub ahead of print]
Zika in Body Fluids
Evidence of Zika virus identified in
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Blood
Semen
Vaginal fluids
Urine
Saliva
Breast milk
CDC.
Potential Risk of Birth Defects Related to Zika
Among pregnant women in the United States with laboratory evidence of possible
Zika virus infection:
◦ Overall about 6% of fetuses or infants had birth defects potentially related to Zika virus
◦ The proportion of pregnancies with birth defects was similar (around 6%) among
symptomatic and asymptomatic pregnant women
◦ Among women with infection in the 1st trimester of pregnancy, birth defects were reported
in 11% of fetuses or infants
Honein MA, Dawson AL, Petersen EE et al. Birth Defects Among Fetuses and Infants of US Women With Evidence of Possible Zika Virus Infection During Pregnancy. JAMA. 2016 Dec 15 [Epub ahead of print]
Johansson MA, Mier-Y-Teran-Romero L, Reefhuis J, Gilboa SM, Hills SL. Zika and the Risk of Microcephaly. N Engl J Med. 2016 May 25 [Epub ahead of print].
Congenital Zika Syndrome
Pattern of congenital anomalies associated with Zika virus infection during
pregnancy that includes
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Severe microcephaly (small head size) resulting in a partially collapsed skull
Thin cerebral cortices with subcortical calcifications
Eye anomalies, including macular scarring and focal pigmentary retinal mottling
Congenital contractures or limited range of joint motion
Marked early hypertonia, or too much muscle tone, and symptoms of
extrapyramidal involvement
Infants with normal head circumference at birth may
◦ Have brain abnormalities consistent with congenital Zika syndrome
◦ Develop microcephaly after birth
Potential Risk of Microcephaly
1 - 13% estimated risk of microcephaly due to Zika virus infection
in 1st trimester
◦ Modeling based on current outbreak in Bahia, Brazil
◦ Not enough data to estimate 2nd or 3rd trimester risk
Important to remember
◦ Data are limited (infection rates unknown; microcephaly cases still
being reported)
◦ Microcephaly is difficult to detect prenatally
◦ Microcephaly is only one of a range of possible adverse outcomes
Johansson MA, Mier-Y-Teran-Romero L, Reefhuis J, Gilboa SM, Hills SL. Zika and the Risk of Microcephaly. N Engl J Med. 2016 May 25 [Epub ahead of print].
Vital Signs: Protecting Pregnant Women
and Babies
April 4th – CDC released latest findings on Zika infection in pregnant women
and babies
Nearly 1,300 pregnant women with evidence of possible Zika infection were
reported to the U.S. Zika Pregnancy Registry.
◦ Of the 1,000 pregnancies that were completed by the end of the year, more than 50
of those babies were born with birth defects.
◦ Among pregnant women with confirmed Zika infection, about 1 in 10 had a fetus or
baby with birth defects.
Confirmed infections in the first trimester posed the highest risk – with about
15% having Zika-related birth defects.
About 1 in 3 babies with possible congenital Zika infection were not reported
to have been tested for Zika at birth.
Only 1 in 4 babies with possible congenital Zika infection were reported to
have received brain imaging after birth.
CDC Guidance: Pregnancy Planning
Zika and Sexual Transmission
Zika can be passed through sex from a person who has the virus
◦ Even if the infected person does not have symptoms at the time.
◦ Before their symptoms start, while they have symptoms, and after their symptoms
end.
◦ Even if the infected person never develops symptoms.
Sex includes vaginal, anal, oral sex, and the sharing of sex toys
Sexual exposure includes sex without a condom with a person who traveled to
or lives in an area with Zika.
Areas with Zika: CDC Travel Notices
Women and Their Partners Thinking
about Pregnancy
Standard Precautions to Prevent the Spread of
Zika Virus and Other Infectious Agents In
Healthcare Settings
Zika Virus Disease in Healthcare Settings
No reports to date of Zika virus from infected patients to healthcare personnel or other patients
in healthcare settings
Zika virus has been detected in blood, amniotic fluid, urine, saliva, and genital fluids (including
semen and vaginal fluids)
Standard Precautions: Personal
Protective Equipment (PPE)
Healthcare personnel education and training in the use of PPE is an Occupational Safety and Health
Administration (OSHA) requirement
Gloves, gowns, face masks, face shields, goggles
Facilities should assure availability and accessibility of PPE to HCP
Educate all HCP on proper selection and correct use of PPE
◦ HCPs must assess their risk for exposure and select appropriate PPE
Examples of obstetric procedures that require increasing amount of PPE
◦ Vaginal exam particularly during amniotomy
◦ Vaginal delivery including manual removal of placenta
◦ Operative procedures
CDC Guidance: Who Should Be Tested
Who Should Be Tested
Pregnant Women
Symptomatic Persons
• People who travel to or
unprotected sex with a person
who recently traveled to an
area with Zika AND
• Present with FRAC symptoms
(fever, rash, arthralgia,
conjunctivitis) within 2 weeks
of exposure
Zika Virus in Indiana
Zika virus disease—United States, 2015–
2016
US States
Indiana
US Territories
Travelassociated
cases
Locally
acquired
cases
Sexually
transmitted
cases
Total cases
5,182
222
45
5,182
53
0
0
53
147
38,156
*
38,303
*Sexually transmitted cases are not reported for US territories because with
local transmission of Zika virus it is not possible to determine whether
infection occurred due to mosquito-borne or sexual transmission.
CDC. Updated April 6, 2017.
Zika Virus Testing at ISDH
ISDH assists in coordinating Zika virus testing based on CDC guidelines:
◦ Travelers to an area with Zika with any of the FRAC (fever, rash, arthralgia,
conjunctivitis) symptoms up to 12 weeks after symptom onset
◦ Individuals with any of the FRAC symptoms who have had unprotected sex with
someone who has traveled to an area with Zika
◦ Pregnant women who have traveled to an area with Zika, regardless of symptoms
◦ Pregnant women who have had unprotected sex with someone who has traveled
to an area with Zika
Zika Virus Authorization
Protocol at ISDH
1.
Ensure patient meets testing criteria
2.
Complete ISDH Zika Authorization Form
◦ Found at isdh.in.gov/zika >> For Providers Section
◦ Fax to ISDH Epidemiology Resource Center at 317-234-2812 to
the attention of Emily Potts, Zika Virus Clinical Coordinator
3.
If the specimen meets testing criteria, the point of
contact will receive an approval email within one
business day of submission.
◦ Email contains instructions on specimen collection and
submission
4.
If a specimen does not meet testing criteria, the point of
contact will receive an email from the Zika Virus Clinical
Coordinator to discuss testing guidelines.
Zika Testing Offered at ISDH
Specimen approved and received at ISDH Laboratories will be tested
and analyzed by either/both:
1.
Trioplex RT-PCR - This test can be performed on a blood or urine
specimen to identify present virus
◦ Results in 2-3 business days from time specimen received
2.
IgM Antibody (MAC-ELISA) - This test can be performed on a blood
specimen to identify a recent past infection after virus is no longer
present in blood or urine
◦ Results in 2-3 weeks from time specimen received
In some cases, additional testing for Zika and dengue antibodies is
needed
◦ PRNT (plaque reduction neutralization test)
◦ This test is done by the CDC and may take four to eight weeks.
CDC.
What Can You Do?
Report Cases & Information to US Zika Pregnancy
Registry
Zika virus infection and disease are nationally notifiable conditions
The following cases should be reported to ISDH:
◦ Symptomatic and asymptomatic cases with laboratory evidence of Zika virus infection
◦ Babies born with or without abnormalities consistent with congenital Zika syndrome and laboratory evidence
of Zika virus infection
US Zika Pregnancy Registry
◦ Purpose of the registry
◦ To monitor pregnancy and infant outcomes following Zika virus infection during pregnancy and to inform clinical guidance and public
health response
◦ Work with Emily Potts, Zika Virus Clinical Coordinator, in cases where additional medical records may be
required
In Summary
Stay up to date on Zika and where it is being
spread
Know the basics about Zika transmission
Educate providers on Zika virus testing
recommendations
Provide support to diagnose and test for Zika for
those with symptoms in your community
Understand the assessment and management of
Zika among pregnant women and infants and how
to protect them from exposure
Inform your local or state health department and
the US Zika Pregnancy Registry as indicated
Thank you!
More information about ISDH Testing
and Authorization:
◦ Emily Potts, Zika Virus Clinical
Coordinator
◦ 317-232-3084, [email protected]
More information on Zika:
www.cdc.gov/zika
Presentation adapted from “Zika Training for Healthcare Providers,” National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease
Control and Prevention (CDC)
The images, written excerpts, and videos included in this presentation are for educational purposes only and may be subject to copyright.
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