1. Zika on the Horizon
Family Practice Review 2/2017 Chelsea Nickolson, DO, MBA

2. Agenda Audience evaluation Microbiology Epidemiology
Screening guidelines
Potential disease effects
Prevention against Zika
Research

3. Zika virus is most similar in its viral class and disease manifestations as which viruses? These viruses should be included in the differential diagnosis.
Ebola and dengue
Dengue and chikungunya
Chikungunya and malaria
Malaria and west nile virus
West nile virus and ebola 10

4. No local transmission in US Only in US territories
Zika virus has been identified with local transmission where in the US?
No local transmission in US
Only in US territories
US territories and a few states
US territories and multiple states
Throughout the US 10

5. Microbiology Arbovirus Family = Flaviviridae Genus = Flavivirus
Isolated 1947 from monkey in Africa (Zika forest)
First outbreak outside Africa/Asia- Yap state, Micronesia (n. pacific)
Picture of female aedes mosquito- credit NIAID

6. Zika Disease Symptoms last days to week
Presumed immunity following infection
Myalgias
Headache
Mosquito bites infected human- zikav lasts for 10-15d in mosquito

7. Presence of Vector Transmission: Potential transmission: Mosquito
Sexual contact
Vertical
Potential transmission:
Blood transfusion
Healthcare associated
Aedes not found at elevations >6500 ft so mountain travel safe but not if travel through lower elevation. Preg women consider should consider the lower o2 content- avoid strenuous activity and consider possible need of medical care in lower elevation.
Article by Musso about polynesia with 3% (2.8% according to cdc) of asymptomatic blood donors +PCR for ZIKAV. 11 of the 42 +zikav had symptoms following transfusion. +in recipient blood but no disease.

8. Pregnancy Effects No increased susceptabilty in pregnancy
No increase in symptoms
Microencephaly of fetus
Other brain abnormalities
Miscarriage
Long term effect on development of babies unknown

9. Zika and Male Reproduction

10. Worldwide
Does not include countries with reported travel-only cases. Cdc.

11. United States

12. Incidence ZIKAV in US US state/territory Travel cases No. (% cases)
Local cases
Texas
287 (6)
6 (3)
Florida
825 (18)
210 (97)
All other US states
3507 (76)
0 (0)
American Samoa
1 (1)
114 (<1)
Puerto Rico
128 (98)
34,045 (97)
US Virgin Islands
2 (2)
862 (3)
cdc
Data as of 1/5/2017

13. Florida

14. Texas

15. Screening Who to screen: Reportable disease
-Symptomatic with exposure within 2 weeks
-Sexual contact with infected person
-Vertical contact
-Travel or sexual contact with partner who traveled to endemic region
Reportable disease
Testing facilitated by health department
Amniotic fluid testing not yet available but under investigation

16. Symptomatic Exposures
Exposure <2 weeks  PCR-NAT
Order PCR-NAT of serum and urine
Exposure >2 weeks  Serum IgM
IgM+ 4 days - 12 weeks from onset of symptoms
Anti-Zika
Anti-Chikungunya
Anti-Dengue
Serum PCR NAT serum and urine should be performed together. +either one confirms zikaD and no further testing needed. NAT- nucleic acid testing. Neg PCR- get IgM

17. Asymptomatic Exposures
Pregnant women with exposure to ZikaV or travel in endemic region
<2 weeks exposure  PCR-NAT
>2 weeks expoure  PCR-NAT only if IgM+
Pregnant women living in endemic region
IgM during 2nd and 3rd trimesters
IgM+ reflex to PCR-NAT

18. Further Diagnostics Trioplex rRT-PCR Zika MAC-ELISA
Detects viral RNA of Zika, Chikungunya, and Dengue
Available only under emergency use authorization
Zika MAC-ELISA
Serum or CSF
Nonspecific among flaviviridae
Confirmation with PRNT by CDC
Zika MAC-ELISA = IgM antibody capture enzyme linkied immunosorbent assay. PRNT= plaque reduction neutralization testing

19. Prevention Avoid mosquito contact Deet Picaridin IR3535
Oil lemon eucalyptus
If infected- avoid mosquitos for 1 week while viral load increased to avoid further transmission to other people. Postpone travel if pregnant to endemic areas

20. Vaccine
Believed feasible due to existing other vaccines against flaviviridae
Phase 1 clinical trial in process for DNA vaccine
Suboptimal dosing in monkeys
Other vaccine modalities being investigated as well
Other considerations
NEJM, Science
Vaccines against yellow fever and japanese encephalitis do exist

21. Resources https://www.cdc.gov/zika/index/html CDC interactive web tool
CDC Digital Media
Text “PLAN” to
Text allows you to enter country/state- response with alert level and link for more info with brief explanation of threat

22. Review Zika differential diagnosis should include other flavivirdae
Symptoms mild viral syndrome
Screen only symptomatic patients with exposure to endemic region or infected person
Adverse effects in fetuses and possible future reproduction

23. Review Continued Prevent exposure with avoidance of mosquitos
Pregnant women should avoid endemic regions
PCR-RT+ or IgM+ confirm diagnosis

24. Questions?

25. References
Center for Disease Control. [website]. January 26,
Hampton T. DNA Vaccine Protects Monkeys Against Zika Virus Infection. JAMA. 2016;316(17):1755. doi: /jama
Hilary D. Marston, M.D., M.P.H., Nicole Lurie, M.D., M.S.P.H, Luciana L. Borio, M.D., and Anthony S. Fauci, M.D. Considerations for developing a zika virus vaccine. N Engl J Med 2016; 375: , September 29, DOI: /NEJMp
Hills Susan, Perkins Kiran. (Producer). (August 2016). Preparing for zika transmission in the US. [Video webinar]. Retrieved from
Hombach Joachim, Friede Martin, Moorphy Vasee, Costello Anthony, Kieny Marie Paule. Developing a vaccine against Zika BMJ 2016; 355 :i5923.
Ma, Wenqiang et al. Zika virus casues testis damage and leads to male infertility in mice. Cell , Volume 167 , Issue 6 , e10.
Musso D, Nhan T, Robin E, Roche C, Bierlaire D, Zisou K, Shan Yan A, Cao-Lormeau VM, Broult J. Potential for Zika virus transmission through blood transfusion demonstrated during an outbreak in French Polynesia, November 2013 to February Euro Surveill. 2014;19(14):pii= Available online: eurosurveillance.org/ViewArticle.aspx?ArticleId=20761.
Ge Li, Melissa Poulsen, Csaba Fenyvuesvolgyi, Yoko Yashiroda, Minoru Yoshida, J. Marc Simard, Robert C. Gallo, and Richard Y. Zhao. Characterization of cytopathic factors through genome-wide analysis of the Zika viral proteins in fission yeast. PNAS : E376-E385.