Zika Virus Infection Thomas M. File, Jr. M.D., M.Sc. Chair, Infectious Disease Division Summa Health System; Professor of Internal Medicine, Chair Infectious Disease Section Northeast Ohio Medical University

Fever in Traveler returning from Caribbean Returning traveler from the Caribbean(5 days) Within 24 hours c/o pain to back of knees, both ankles and feet, wrists and hands-symmetric, no swelling nor erythema, lasted 3-4 days Severe spinal pain, inability to stand upright -3 days Fevers –constant for up to 72 hours 101-102F Malaise, myalgia, fatigue for 1 week 2-3 days later, faint erythema to trunk, followed by photosensitivity rash to arms face legs-transient pruritus No headaches, URI symptoms

Chikungunya Viral infection No person-to-person transmission No vaccine or treatment No person-to-person transmission Mosquito vectors Aedes aegypti or Aedes albopictus widespread Mosquitoes can “hitchhike”

Chikungunya The mosquitoes Symptoms Aedes species; same types for dengue virus Bite mostly during the daytime Symptoms Usually begin 3‒7 days after being bitten by an infected mosquito Most common symptoms are fever and severe joint pains, often in the hands and feet Joint pains persist in 50% for > 1 year Other symptoms may include headache, muscle pain, joint swelling, or rash

Chikungunya Sudden high fever (usually >102º F) which may be continuous or intermittent Severe joint pain that commonly involves the hands and feet Joint swelling Back pain Rash usually 2-5 days after fever starts Other symptoms may include headache, body ache, nausea, vomiting, and redness around the eyes. In unusual cases, infection can involve the brain, eyes, heart, kidney and other organs.  Fatal infections are rare, however many patients have chronic joint pain, arthritis, loss of energy and depression lasting weeks to years.

Differential diagnosis Chikungunya vs Dengue viral fever Dengue more pronounced retro-orbital pain More commonly hypotension and mild bleeding complications Fatigue can last for months Associated with higher mortality ?influenza-like, but no URI symptoms Outbreak Dengue in Hawaii (Nov, 2015, Big Island)

Diagnostic testing Performed on the 3rd day given persistent symptoms CBC, mild lymphopenia, mild thrombocytopenia LFT not done Mild CPK elevation Chikungunya PCR+ Other options: paired sera for Chikungunya IgM

Treatment/Prevention Chikungunya Treatment/Prevention No medication to treat or prevent infection Vaccine under development Reduce mosquito exposure Use air conditioning or window/door screens Use mosquito repellents on exposed skin. Repellents containing DEET, picaridin, IR3535, and some oil of lemon eucalyptus and para-menthane-diol products provide long lasting protection. Wear long-sleeved shirts and long pants Empty standing water from outdoor containers Support local vector control programs

Flaviviridae virus family; related to dengue, West Nile, Chikungunya Started Uganda; new to West Hemisphere, Fla….. Transmission: Mosquitoes, Sexual contact, ?other Incubation: 2-12 days Only 1 in 5 people infected with Zika virus experience symptoms fever, rash, joint pain and conjunctivitis, and sometimes headaches, muscle pain and vomiting. The illness lasts about a week. linked to some alarming complications-microcephaly in fetuses of infected pregnant women; Guillan Barre Syndrome……. Test: PCR of blood (within 7-14 days illness); Serology (after 14 days)

TRANSMISSION

Zika Virus Clinical Course Clinical course usually mild Symptoms last several days to a week Severe disease requiring hospitalization infrequent Fatalities rare Neurologic sequelae uncommon

Neurologic manifestations of Zika virus Burden higher than Microcephaly Other Childhood concerns Other neurological sequelae: GBS Encephalitis Myelitis Acute disseminated encephalomyelitis (ADEM) Opsoclonus-myoclonus-ataxia syndrome( OMS) James J. Sejvar, MD, Neuroepidemiologist CDC. Nov 11, 2016

ZIKA SYMPTOMS Typically starts on face ; spreads

NEJM March 3, 2016

ZIKA: Therapy Prevention

72 Pregnant women + Zika; 5-38 wks gestation Pred features; pruritic descendng rash (maculopapulrar), arthralgia, HA; 28% fever, lymphadenopthy 42 with fetal US Abn in 12 (29%) Fetal death-2 Growth restriction with or without microcephaly- 5 CNS lesions- 7; ABN cerebral or umbilical artery flow-7 Conclusion: Despite mild clinical symptoms, ZIKV infection during pregnancy appears to be associated with grave outcomes, including fetal death, placental insufficiency, fetal growth restriction, and CNS injury NEJM March 3, 2016

NEJM March 3, 2016

Zika and Microcephaly: US Report from CDC 2/25/2016 9 woman with + tests (of 257 tested) 3 delivered: 2 healthy, 1 microcephaly 2 had miscarriages 2 abortions: one with microcephaly 2 pregnancies continuing 2 of nine delivered healthy babies, but two still pregnant 2 confirmed microcephaly

Zika: US Report 10/26/2016 Total 32,814 99% in territories: PR, VI…. Locally acquired: 28,289 99% in territories: PR, VI…. 139 in FLA Travel related 4048 Preg outcomes in 50 US States 25 births with defects.

CDC Recommendations: Pregnancy If pregnant avoid travel to areas of Zika infection Male partners to areas should abstain or use condoms during entire pregnancy if traveled to area of Zika infection; avoid impregnation for 6 months If Pregnant and has traveled to area of Zika infection See algorithm next slide If not pregnant but child bearing age and going to area of Zika infection Use reliable birth control (50% pregnancies in US unplanned) Mosquito avoidance Avoid pregnancy 2 months

ZIKA Vaccine Under Development In June 2016 the FDA granted the first approval for a human clinical trial for a Zika vaccine.

Healio Outbreak Tracker. Nov 24, 2016

Healio Outbreak Tracker. Nov 28, 2016