Zika outbreak in the Americas Dr Zika outbreak in the Americas Dr. Marcos Espinal Director, Communicable Diseases & Health Analysis

Chronology of ZIKV events 1947 First isolation of ZIKV in rhesus monkeys in the Zika forest in Uganda. 1952 First isolation of ZIKV in humans in Uganda and Tanzania. 1970s Sporadic cases reported in other African countries, India and Southeast Asia (Malaysia, Thailand, Vietnam, Indonesia) 2007 First major Zika fever outbreak in Yap Island – Micronesia 2013 Larger Zika fever outbreak in French Polynesia 2014 Zika fever reporting in other Pacific Islands and Chile (Easter Island). 2015 May – Brazil reports Zika transmission 15 countries and territories of the Americas confirmed the circulation of the Zika virus. 2016 28+ countries and territories confirmed cases

Historical spread of Zika virus Isla de Pascua

Current Spread of Zika virus Aruba, Barbados, Bolivia, Brazil, Bonaire, St Eustatius, Saba, Colombia, Costa Rica, Curaçao, Dominican Republic, Ecuador, El Salvador, French Guiana, Guadeloupe, Guatemala, Guyana, Haiti, Honduras, Jamaica, Martinique, Mexico, Nicaragua, Panama, Paraguay, Puerto Rico, Saint Martin, Suriname, Trinidad & Tobago, US Virgin Islands, Venezuela

Rates of Microcephaly by State in Brazil 2010-2014 vs 2015-2016 1/14/2016 10

Zika Epidemic in Brazil, 2015-16 209,000,000 total population, 5 Regions and 24 States In May 2015, first cluster of locally acquired Zika cases reported from Northeast Region (Pernambuco state). Estimated > 1,000,000 persons exposed to ZIKV throughout the country by end 2015. First report of increase in microcephaly in Oct 2015. End January 2016, a total of 4,783 cases of microcephaly reported vs 156 cases per year, 2010-2014.

Zika epidemic and GBS Countries reporting increased incidence of Guillain-Barre Syndrome and Zika prevalence: Brazil El Salvador Columbia Suriname Venezuela Media reports in Puerto Rico and Honduras have not been confirmed Martinique has reported no increase of GBS, but is reporting cases of GBS among lab-confirmed cases of Zika

Clinical presentation ZIKV infection All people living in or travelling to Aedes infested areas are susceptible to ZIKV infection if they have not been exposed to the virus before. Only 20% of infected people develop symptoms consistent with Zika disease, mainly fever and skin eruption or rash, muscle or joint pain, conjunctivitis “red eyes”, fatigue and general malaise. So, about 80% of exposed persons are unaware of the infection. Most cases recover within a few days of illness. Complications are rare but can be debilitating or fatal.

Clinical Presentation of rash syndrome in Northeast Brazil, May 2015 1/14/2016 Clinical Presentation of rash syndrome in Northeast Brazil, May 2015 Rash, swollen joints, and conjunctival hyperemia Source: Research team of the São Luís/MA municipal health office - From a presentation by the Ministry of Health of Brazil, 2015 10

1/14/2016 First reports in Brazil: Unusual increase of newborns with microcephaly, November 2015 Photo credit: Image provided by mother of newborn (Rio de Janeiro, Brazil), with authorization for dissemination exclusively among public health workers. 31

January 2017: On recommendation of Emergency Committee, WHO DG declares a Public Health Emergency of International Concern for the recent cluster of microcephaly cases and other neurological disorders reported in Brazil, following a similar cluster in French Polynesia in 2014.

PAHO/WHO Strategy to respond to Zika virus www.paho.org/zikavirus Promote research and generation of evidence DETECT Early detection of the virus, its sequelae and monitoring the evolution of the epidemic PREVENT Risk reduction by reducing vector density and opportunities for transmission RESPOND Response management, including preparation of health facilities, recommendations for clinical management, risk communication, resource mobilization and logistics

Treatment and Care No specific treatment or vaccine yet available for Zika fever. Treatment is therefore symptomatic and supportive: Regular fluid intake to prevent dehydration Acetaminophen/Paracetamol to reduce fever and pain Aspirin and NSAIDs, e.g. naproxen, ibuprofen, are not recommended due to increased risk of haemorrhage if dengue has not been ruled out Resting under a bednet to avoid onward transmission Admission of complicated cases in hospital for close monitoring and supportive care, e.g. ICU/ventilation for GBS cases.

Prevention & Protection Prevent yourself being bitten Wear long sleeves and long trousers Use insect repellent Screen your house where possible Reduce breeding of Aedes in and around your home Check your property at least twice a week for breeding sites Cover used water storage containers Empty unused containers & plant drip trays & remove Remove rubbish from your yard Dislodge eggs from vases, containers, plant drip trays

Impact of ZIKV epidemic Increased burden on the health care delivery system with limited capacity to deal with a sudden influx of cases and/or lack of capacity to treat complications. Economic implications: Restriction of travel to affected areas with negative impact on tourism revenues. Depletion of government funds due to a sudden need for finances to mount an effective response. Prolonged absenteeism from work with adverse effect on productivity.

Risk of Dengue virus transmission = risk of Zika virus transmission Source: Murray NE, Quam MB, Wilder-Smith A. Epidemiology of dengue: past, present and future prospects. Clinical epidemiology. 2013;5:299.

Possible Geographic Distribution of Aedes aegypti Kraemer MUG, et alii, eLife 2015;4:e08347

Zika Virus Knowledge Gaps We need to do the following: Develop virological tests to improve detection in context of high circulation of other flaviviruses Determine causal link between ZIKV and microcephaly and other neurological disorders Determine the associated incidence of neurological effects (GBS and other neurological and autoimmune syndromes) Determine modes of transmission – sexual, transfusions, vertical Develop vaccine / antiviral medications Study vector competency and develop new tools for vector control

Recommendations for PAHO/WHO Member States Multisectorial coordinated approach for vector control and management, partnering with and engaging relevant stakeholders and the community Surveillance strengthening for arboviruses, birth defects and GBS Health services preparedness for the management of potential complications including neurological syndromes and birth defects Risk communication and public awareness WHO encourages affected countries and their partners to boost the use of current mosquito control interventions as the most immediate line of defense, and to judiciously test new approaches that could be applied in future.

PAHO support Monitoring the spread of ZIKV infection through a network of national IHR focal points throughout the Region Assisting countries in assessing risk and strengthening surveillance systems including the monitoring of complications Building capacity of laboratories to detect ZIKV Guiding countries on appropriate vector control strategies Preparing recommendations for clinical management and monitoring persons with ZIKV infection Defining and supporting priority areas of research into Zika virus disease and possible complications

The Vector

Aedes Aegypti Daytime mosquito – dawn and dusk; however due to LED light use is thought to be active at night Limited movement – flying radius of 500m Female lays ~80 eggs every 3 days Needs blood meal to lay eggs Eggs can survive several years out of water 4 stages of the lifecycle, 3 are water related Well adapted to human habitats (water storage, waste, white lights, air conditioning, bromeliads)

Bromeliads and house plants

Prevention of Dengue, Chikungunya & Zika Protect yourself from being bitten Prevent mosquitos breeding in and near your home

Prevent mosquitos breeding in and near your home

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