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

2. 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.
countries and territories confirmed cases

3. Historical spread of Zika virus
Isla de Pascua

4. 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

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

7. 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,

8. 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

9. 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.

10. 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

11. 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

12. 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.

13. 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

14. 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.

15. 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

16. 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.

17. 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.

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

19. 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

20. 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.

21. 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

22. The Vector

23. 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)

24. Bromeliads and house plants

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

26. Prevent mosquitos breeding in and near your home

27. THANK YOU