1. Griffin Hospital Occupational Medicine Center Barry S. Ostroff, MD, FACOEM June 7, 2016

2. 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?

3. 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

4. ZIKA VIRUS ENDEMIC AREAS IN THE AMERICAS

5. 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

6. TRANSMISSION

7. MODES OF TRANSMISSION TO HUMANS Mosquito bites Sexual contact Blood and body fluids exposure

8. Aedes aegypti mosquitoes can become infected when they bite infected persons and can then spread the Zika virus to other persons they subsequently bite.

9. 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.

10. 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*

11. 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

12. SYMPTOMS Symptoms are similar to those of dengue fever or chikungunya: Fever Rash Joint pain Conjunctival injection Myalgia Headache Rarely neurological and autoimmune complications

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Hats and Clothing with Mosquito Netting

20. 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

21. 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

22. 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

23. 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 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 Permethrin- treated bed nets

24. 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

25. 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

26. 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?

27. 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?

28. 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?

30. Thank you!