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Transcript
Griffin Hospital Occupational Medicine Center
Barry S. Ostroff, MD, FACOEM
June 7, 2016
Case Presentation
 GH is a 24 y.o. pregnant ED nurse who presents to your clinic for follow-up
following a needle stick exposure to blood
 The source patient gave a history that he had returned the prior day from a
business trip to Brazil and several other South American countries
 Source patient’s presenting symptoms:
 3 day history of fever, rash, joint pain, myalgia, and headache
 What concerns do you have regarding this potential Bloodborne Pathogen
Exposure?
BRIEF HISTORY OF ZIKA VIRUS
 First case identified in the Zika Forest in Uganda in 1947
 Originally endemic to Africa, Southeast Asia, and the Pacific Islands
 In 2015, cases of Zika virus infection emerged in the Americas and the
Caribbean
ZIKA VIRUS ENDEMIC AREAS IN THE AMERICAS
EPIDEMIOLOGY
 Primarily spread through the bites of infected mosquitoes
 Mosquitoes become infected when they bite infected persons and then
spread the Zika virus to other persons they subsequently bite.
 Aedes species mosquitoes (females) are a principal potential vector of
Zika virus in the U.S.
 Aedes aegypti are typically concentrated in the southern U.S. as well as
parts of the Southwest.
 Aedes albopictus are found in much of the southern and eastern part of the
U.S.
 Aedes mosquitoes can also carry other arboviruses including Yellow
Fever, Dengue, Chikungunya, Japanese Encephalitis, and West Nile
Virus
TRANSMISSION
MODES OF TRANSMISSION TO HUMANS
 Mosquito bites
 Sexual contact
 Blood and body fluids exposure
Aedes aegypti mosquitoes can become infected when they bite infected
persons and can then spread the Zika virus to other persons they
subsequently bite.
Aedes albopictus originated in Asia and has adapted to survive in a broader
temperature range and at cooler temperatures, which enables them to persist in
more temperate climates.
DISTRIBUTION OF POTENTIAL MOSQUITO VECTORS IN THE US
Estimated range of Aedes aegypti in
the United States, 2016*
Estimated range of Aedes albopictus in
the United States, 2016*
Zika Virus Infection in Humans




Approximately one out of five infected people develop symptoms
Incubation period 2-7 days
Symptoms are usually mild and can last 2–7 days
Infectious virus particles can be detected in the blood during the first
week of infection
 Zika virus can be spread transplacentally from a pregnant woman to
her fetus potentially resulting in microcephaly, other brain
abnormalities, eye defects, hearing deficits, and impaired growth
SYMPTOMS
 Symptoms are similar to those of dengue fever or chikungunya:
 Fever
 Rash
 Joint pain
 Conjunctival injection
 Myalgia
 Headache
 Rarely neurological and autoimmune complications
DIAGNOSIS
 Typical symptoms with history of travel to an endemic area or other means of





exposure by patient or sexual partner
Reverse transcriptase-polymerase chain reaction (RT-PCR) within first few
days is preferred test for Zika but a negative test does not rule out diagnosis
A recent study found RT-PCR testing in urine more sensitive than serum
Virus-specific IgM antibodies may be detectable >4 days after onset of illness
but strong cross reactivity between Zika virus and other flaviviruses such as
dengue and chikungunya occur
IgM antibodies typically persist for approximately 2-12 weeks
A negative Zika IgM result obtained 2-12 weeks after potential exposure
suggests that infection did not occur
TREATMENT
 There is no specific medical treatment
 Symptomatic Treatment:
 Rest
 Copious fluids
 Acetaminophen (Tylenol®) to reduce fever and pain.
 Do not take aspirin and other NSAIDS until dengue fever can be ruled out
 Supportive treatment for complications
Zika in the U.S. (as of April 20, 2016)
Note: Zika virus disease and Zika virus congenital infection are nationally notifiable
conditions.
US States
 Travel-associated cases reported: 503
 Locally acquired vector-borne cases reported: 0
 Total: 503
 Pregnant: 48
 Sexually transmitted: 10
 Guillain-Barré syndrome: 1
US Territories
 Travel-associated cases reported: 3
 Locally acquired cases reported: 698
 Total: 701
 Pregnant: 65
 Guillain-Barré syndrome: 5
http://www.cdc.gov/zika/geo/united-states.html
Zika in the U.S. (as of June 1, 2016)
Note: Zika virus disease and Zika virus congenital infection are nationally notifiable
conditions.
US States
 Travel-associated cases reported: 618
 Locally acquired vector-borne cases reported: 0
 Total: 618
 Sexually transmitted: 11
 Guillain-Barré syndrome: 1
US Territories
 Travel-associated cases reported: 4
 Locally acquired cases reported: 1,010
 Total: 1,014
 Guillain-Barré syndrome: 8
http://www.cdc.gov/zika/geo/united-states.html
If Zika Virus Becomes Endemic in US…
 Employers should train workers about their risks of exposure to Zika virus
and how to protect themselves
 Exposure through mosquito bites
 Exposure through direct contact with infectious blood and other body fluids
 Employers should provide education about Zika virus infection
 Modes of transmission
 Links to birth defects
 Workers who are pregnant or may become pregnant
 Male workers whose sexual partners may become pregnant
 Prevention of potential exposure is key since a vaccine is not available
Outdoor Workers
 Use insect repellants
 Protective clothing
 Cover exposed skin
 Hats with mosquito netting to protect face and neck
 Clothing with mosquito netting to protect body and hands
 Socks that cover ankles and lower legs
 Eliminate sources of standing water where mosquitos breed
 Consider reassignment of employees
 Employee currently is or planning to become pregnant
 Male with sexual partner who is or may become pregnant
Hats and Clothing with Mosquito Netting
Use of Insect Repellants
 EPA registered active ingredients
 Exposed skin application



DEET
Picaridin
Oil of lemon eucalyptus (OLE) or para-menthane-diol (PMD)
 For clothing and gear only

Permethrin – Acts as an Insecticide
 Protection Times
 Higher concentrations, greater protection times



4.75% DEET – 1 hour
23.8% DEET – 5 hours
DEET Concentrations above 50% - no additional benefit
Use of Insect Repellants (continued)
 Do not apply to irritated or broken skin
 Do not apply under clothing
 When returning indoors and before eating, wash with soap and
water
Use of Sunscreen and Insect Repellants
 Approximately 1/3 decrease in SPF when DEET containing products used
with Sunscreens
 Combination Sunscreen and Insect Repellant products not recommended
 Apply Sunscreen first, then Insect Repellant
 May need to reapply Sunscreen more frequently
International Business Travelers
 Avoid travel to Zika infected areas
 Check CDC Website for most up to date information:
http://wwwnc.cdc.gov/travel/page/zika-travel-information
 Critical for women of childbearing age who are pregnant or planning on
becoming pregnant as well as their spouses and sexual partners
 If travel to infected areas unavoidable
 Strict adherence to mosquito bite preventive measures
 Wear light colored long-sleeved shirts and long pants
 Use EPA approved insect repellents
 Treat clothes with permethrin
 Work and sleep in well-screened buildings
 If sleeping in poorly screened accommodations or outdoors, use Permethrintreated bed nets
International Business Travelers
 Upon return from Zika infected areas even if asymptomatic:
 Practice strict adherence to mosquito bite preventive measures for 3
weeks
 Males
 Prevent potential sexually spread infection through condom use or
abstinence


If diagnosed with Zika or has had symptoms, for at least 6 months
Male partner with no symptoms, for at least 8 weeks after the male returns
Healthcare and Clinical Laboratory Workers
 Strict adherence to good infection control and biosafety practices
 Universal Precautions for potential BBP exposures
 Use of appropriate PPE including gloves, gowns, masks, shields, eye and
mucous membrane protection
 Hand Hygiene before and after contact with patients, potentially infectious
materials, and before putting on and removing PPE
 Laboratories handling Zika Virus must comply with BSL-2 guidelines and
BSL-3 precautions for some procedures
 Engineering controls
 Appropriate evaluation and follow-up of potential employee exposures
Case Presentation
 GH is a 24 y.o. pregnant ED nurse who presents to your clinic for
follow-up following a needle stick exposure
 The source patient gave a history that he returned the prior day from a
business trip to Brazil and several other South American countries
 Source patient’s presenting symptoms:
 3 day history of fever, rash, joint pain, myalgia, and headache
 What are your concerns regarding this potential Bloodborne Pathogen
Exposure?
Case Presentation (Continued)
 The source patient’s HIV, Hepatitis B, and Hepatitis C testing was
negative
 Source’s blood was positive for virus specific IgM
 Source’s Zika virus RT-PCR was positive in both blood and urine
 What is your recommendation regarding an appropriate follow-up
protocol for the employee?
Unanswered Questions
 Would a therapeutic abortion be a compensable procedure?
 Is microcephaly or other developmental brain abnormality found in the
offspring compensable?
 Assuming Zika virus becomes endemic in the US, is a temporary
reassignment to an indoor position of an outdoor female worker currently
planning pregnancy or a male with a sexual partner who is or may become
pregnant a reasonable accommodation?
 What if temporary reassignment to an indoor position not possible?
 Who is financially responsible for the potential consequences of
workplace exposure?
Thank you!