Download Zika Update - Indian River County Medical Society

Zika Update
Laurie Welton, D.O.
Miranda Hawker, MPH, County Health Officer
Doug Carlson, Executive Director, Indian River Mosquito Control
Zika Virus
 Flavivirus
 Originally identified in Africa and Southeast Asia
 First identified in Uganda’s Zika Forest in 1947
 Outbreaks since 2007
 Spread by the same mosquito species as dengue,
chikungunya and yellow fever
Transmission
 Mosquito bite (Aedes aegypti, Aedes albopictus)
 Sexual transmission
 Transmission in the womb and at the time of birth
 Blood transfusion
Incubation and Viremia
 Incubation period generally 3-14 days
 Viremia ranges from a few days to one week
 Virus generally detectable in blood for 7 days after
symptom onset
 Virus generally detectable in urine for 14 days after
symptom onset
 Virus has been detected in semen up to 6 months
4
Zika Fever Clinical Presentation
 1 in 5 people infected will become symptomatic
 Presentation similar (but milder) to other arboviral
diseases common in same endemic areas
 Differential: Dengue, Chikungunya, Leptospirosis,
Malaria, Rickettsia, Rubella, Measles, Group A
Strep, Parvovirus, Enterovirus, Adenovirus
 Most common signs and symptoms:
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 Fever (often low-grade)
 Myalgia
 Maculopapular rash
 Headache
 Arthralgia
 Retro-orbital pain
 Conjunctivitis
 Vomiting
Symptom Comparison
Zika
Birth defects
Guillain-Barré Syndrome
Dengue
Fever*
Chikungunya
Potentially fatal
Hemorrhagic shock
Joint pain which can
last for years
• Fever
• Fever
• Headache
• Headache
• Joint pain
• Joint pain
• Muscle pain
• Muscle pain
• Heat rash
• Heat rash
• Nausea & vomiting
• Nausea & vomiting
• Conjunctivitis
(red eyes)
• Pain behind eyes
•
•
•
•
•
•
•
Fever
Headache
Joint pain
Muscle pain
Heat rash
Nausea
Conjunctivitis
(red eyes)
*Additional symptoms for dengue hemorrhagic fever and dengue shock syndrome
Zika Fever (continued)
 Symptomatic treatment
 Typically resolves within a week
 Coinfections with other flaviviruses possible and should be
considered, so avoid aspirin and similar drugs (e.g.,
NSAIDs)
 Severe disease requiring hospitalization is uncommon
and fatalities are rare
 Infection during pregnancy (especially in first and
second trimesters) is associated with microcephalic
infants and/or other poor pregnancy outcomes
 Increasing evidence of association with Guillain-Barré
Syndrome (GBS) post-infection
7
Birth Defects Linked to Zika
 Microcephaly (decreased brain tissue)
 Calcium deposits
 Excess fluid
 Absent or poorly formed brain structures
 Abnormal eye development
 Fetal Brain Disruption Sequence
 Many other adverse outcomes
Guillain-Barré Syndrome (GBS)
Suspect Zika Infection?
Infection with Zika should be suspected in:
1
0
1.
All persons, including pregnant women, with two or more of
the following signs/symptoms: fever, maculopapular rash,
arthralgia or conjunctivitis (GBS could follow) and a history
of travel to an area with Zika virus activity in the two weeks
prior to illness onset
2.
Mother of an infant or fetus with microcephaly or
intracranial calcifications or other abnormalities, or poor
fetal outcome diagnosed after the first trimester and history
of travel to an area with Zika virus activity during pregnancy
(Testing of both the mother and infant is recommended)
Suspect Zika Infection?
1
1
3.
Infants of symptomatic or asymptomatic pregnant
women who traveled to an area reporting Zika virus
activity while pregnant (testing of both mother and
infant is recommended)
4.
Suspect local cases in a county/area with no
reported local Zika virus infections and three or
more of the following signs/symptoms: fever,
maculopapular rash, arthralgia or conjunctivitis
5.
Suspected Zika virus associated GBS cases
Florida Case Example 1
 Female, early 40s
 Office visit on 1/26/2016
 CC: red eyes, hives generalized, pain fingers (joints),
fatigue
 Travel history (Haiti) for two weeks (1/11 – 1/25)
 Rash started on 1/22 resolved before (mild pruritus),
arthralgia 3 days, fatigue and malaise
 Recalls mosquito bites while overseas
 Physical unremarkable
 Laboratories
 ZIKAV PCR/RNA Amplification (serum) Negative
 ZIKAV PCR/RNA Amplification (urine) Positive
 DENGUE FEVER ABS, IGG = 11.46 (H)
1
2
Florida Case Example 2
 Female, late 50s
 Office visit on 2/2/2016
 CC: fever, joint pain, headache, nausea, and rash (onset
1/30/16)
 Travel history to PR (returning 1/29/2016)
 Family member in PR diagnosed with Zika (Dx on 1/25/16?)
 No information on physical
 Laboratories
 ZIKAV PCR/RNA Amplification (serum) Equivocal
 ZIKAV PCR/RNA Amplification (urine) Positive
1
3
Countries & Territories with Active Zika Transmission
Source: CDC, October 26, 2016
Current Status
 Florida (as of Oct.31)
 183 non-travel related Zika cases
 United States
 3, 951 travel-associated cases (10/26/16 CDC)
 US Territories
 28, 723 locally acquired cases in US Territories
(10/26/16 CDC)
Bay
Brevard
Broward
Charlotte
Citrus
Clay
Collier
Duval
Escambia
Flagler
Hernando
Highlands
Hillsborough
Lake
Lee
Leon
Manatee
Marion
Martin
Miami-Dade
Monroe
Nassau
Okaloosa
Okeechobee
Orange
Osceola
Palm Beach
Pasco
Pinellas
Polk
Santa Rosa
Sarasota
Seminole
St. Johns
St. Lucie
Volusia
3
15
130
2
2
6
9
9
3
2
4
1
26
3
12
2
4
3
2
249
6
1
3
1
88
30
41
8
19
28
1
5
22
4
7
10
Zika Travel-Related Cases by County, Florida
October 31, 2016
Total travel related cases not
771
involving pregnant women
Cases involving pregnant
124
women
CDC Health Advisory (10/20/2016)
 Pregnant women
 Postpone travel to Miami-Dade County
 Be tested for Zika if
 Has an epidemiologic link* to Miami-Dade Co since August 1, 2016
 Has an epidemiological link* to Miami Beach since July 14, 2016
 Women and men planning to conceive
 Avoid travel to areas with active transmission
 Postpone conception based on CDC recommendations
*Lived in, traveled to, or had unprotected sex with someone who lived in
or traveled to the designated.
Emergency Rules Noticed
 Noticed February 5, 2016
 64DER16-1 (64D-3.029) Diseases or Conditions to be
Reported
 Requires immediate reporting to DOH of suspected or
confirmed cases of the Zika virus by physicians, hospitals,
and laboratories. Reporting should occur immediately as
soon as infection is suspected but does not need to occur
after hours.
 Reporting should occur upon initial suspicion of infection
(prior to testing) to ensure effective mosquito control
efforts can begin as soon as possible, to reduce the
possibility of local transmission.
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9
State and Local Actions
 Executive Order Number 16-29
 Directs State Health Officer (SHO) and Surgeon General
to declare Public Health Emergency in counties with
imported cases
 Directs meetings be convened by the County Health
Officer in the impacted counties to discuss mosquito
control best practices and outreach to communities with
high risk or vulnerable populations
 County Health Officers for affected counties develop
outreach program for local medical professionals to
increase awareness and access to diagnostic tools
2
0
Response to Zika Virus
 Communication
 Surveillance
 Lab testing
 Vector control
 Outreach to pregnant women
 Blood supply safety
Zika Testing
 Commercial testing is available through Quest & LabCorp
 Criteria for testing
 Possible exposure (travel or sexual) AND 2 or more of the
following: (fever, maculopapular rash, arthralgia, conjunctivitis)
 Any pregnant woman with possible exposure (travel or sexual)
regardless of symptoms
 Any person with 3 of the above signs/symptoms with no travel
(suspected local case)
 Patients meeting the above criteria who are uninsured can be
tested through the Health Department at no cost.
 Pregnant women without possible exposure who insist on
testing after counseling, and who are uninsured can be
tested through the Health Department
Reporting suspected cases of Zika virus
infection
 Complete Zika risk factor
questionnaire
 Fax to DOH – Indian River
at 772-794-7482
 Order testing through a
commercial laboratory
Only two Florida
mosquito species can
transmit Zika, dengue
or chikungunya
viruses!
Virus transmission
cycle
Aedes aegypti
“Yellow fever mosquito”
Aedes albopictus
“Asian tiger mosquito””
Blood-feeding female
Emerging adult
Eggs
Basic Mosquito
Life Cycle
Pupa
Larva
Mosquitoes that transmit Zika, dengue and chikungunya viruses
come from water sources like this…
or like this…
Mosquitoes that transmit Zika, dengue and
chikungunya viruses never lay their eggs in
“standing water” on the ground!
Water in ditches, marshes, ponds or canals
is irrelevant to Zika, dengue, or
chikungunya transmission
Artificial and natural containers are the
only sources of concern.
Characteristics of mosquitoes transmitting
Zika, dengue or chikungunya viruses
• Aggressive day-time biters
• Aquatic stages in artificial containers, bromeliads,
treeholes
• Short flight-range; adults stay close to hatching site
Control of mosquitoes transmitting
Zika, dengue or chikungunya viruses
• Control of adults is a problem (these mosquitoes are not
flying at night when spraying is most common)
• Targeted spraying around infested residences can help
• Elimination of container habitats around homes and work
places is the only truly effective control measure!