1. Zika Update Laurie Welton, D.O.
Miranda Hawker, MPH, County Health Officer
Doug Carlson, Executive Director, Indian River Mosquito Control

2. Zika Virus
Flavivirus
Originally identified in Africa and Southeast Asia
First identified in Uganda’s Zika Forest in 1947
Outbreaks since 2007
Spread by the same mosquito species as dengue, chikungunya and yellow fever
Flavivirus: also include yellow fever, dengue, WNV
- 1st isolated in Uganda in 1947 from a Rhesus macaque in Zika Forest. Isolated during a study on yellow fever. Present in Africa and SE Asia – represent two main lineages of the virus. Only total 14 human cases identified in these areas and several countries only have evidence of transmission from serosurvey data. In East Africa – sylvatic cycle between nonhuman primates and several Aedes mosquito species. Humans are the primary amplifying host during outbreaks.
Aedes aegypti believed to be primary vector and other Aedes species have played important roles during recent Western Pacific outbreaks. Aedes albopictus may have the potential to transmit.
2007 – 1st major outbreak on island of Yap in Micronesia. Over 100 confirmed and probable (49+59=108) and 72 suspected = 180). Seroprevalence study (74% pos) estimated that around 73% (over 5,000) of the population had been infected and only 18% had a clinical illness (900).
2013 – outbreak in French Polynesia . Since then, spread to other Pacific Islands, with over 30,000 suspected cases.
May 2015 – identified in Brazil
2015 PR / Guatemala isolates – Asian lineage (E. & W. Africa and Asian lineages)

3. Transmission Mosquito bite (Aedes aegypti, Aedes albopictus)
Sexual transmission
Transmission in the womb and at the time of birth
Blood transfusion
Mosquito-borne spread is by far the most important mode of transmission
Mother to fetus at delivery, or during pregnancy – rare (transmission through breast milk has not been documented)
Sexual transmission: can spread from infected people (men or women) to their sex partners; virus can be in semen longer than blood (90 + days) – don’t know how long it is shed.
Blood transfusion: Zika virus RNA has been identified in 3% of asymptomatic blood donors during an ongoing outbreak in French Polynesia. No cases have been identified in the US from transfusion transmission. One Blood now screening donations.

4. Incubation and Viremia
Incubation period generally 3-14 days
Viremia ranges from a few days to one week
Virus generally detectable in blood for 7 days after symptom onset
Virus generally detectable in urine for 14 days after symptom onset
Virus has been detected in semen up to 6 months

5. Zika Fever Clinical Presentation
1 in 5 people infected will become symptomatic
Presentation similar (but milder) to other arboviral diseases common in same endemic areas
Differential: Dengue, Chikungunya, Leptospirosis, Malaria, Rickettsia, Rubella, Measles, Group A Strep, Parvovirus, Enterovirus, Adenovirus
Most common signs and symptoms:
Causes an illness similar to dengue, but the symptoms are milder. Illness characterized by low-grade fever, maculopapular rash (face, neck, trunk, and upper arms, which may spread to the palms and soles), arthralgia, myalgia, and conjunctivitis.
Approximately 25-35% of cases may be afebrile.
Symptoms resolve over 4-7 days.
Severe disease requiring hospitalization is uncommon and case fatality is low.
Signs and symptoms in red box represent the most common found in patients with Zika.
Based on the typical clinical features, the differential diagnosis for Zika virus infection is broad. In addition to dengue, other considerations include leptospirosis, malaria, rickettsia, group A streptococcus, rubella, measles, and parvovirus, enterovirus, adenovirus, and alphavirus infections (e.g., Chikungunya).
Fever (often low-grade)
Myalgia
Maculopapular rash
Headache
Arthralgia
Retro-orbital pain
Conjunctivitis
Vomiting

6. Symptom Comparison Dengue Fever* Zika Chikungunya Fever Headache
Birth defects
Guillain-Barré Syndrome
Potentially fatal Hemorrhagic shock
Joint pain which can
last for years
Fever
Headache
Joint pain
Muscle pain
Heat rash
Nausea & vomiting
Conjunctivitis (red eyes)
Fever
Headache
Joint pain
Muscle pain
Heat rash
Nausea & vomiting
Pain behind eyes
Fever
Headache
Joint pain
Muscle pain
Heat rash
Nausea
Conjunctivitis (red eyes)
Main concern about Zika: birth defects and GBS.
*Additional symptoms for dengue hemorrhagic fever and dengue shock syndrome

7. Zika Fever (continued)
Symptomatic treatment
Typically resolves within a week
Coinfections with other flaviviruses possible and should be considered, so avoid aspirin and similar drugs (e.g., NSAIDs)
Severe disease requiring hospitalization is uncommon and fatalities are rare
Infection during pregnancy (especially in first and second trimesters) is associated with microcephalic infants and/or other poor pregnancy outcomes
Increasing evidence of association with Guillain-Barré Syndrome (GBS) post-infection
Because of similar geographic distribution and symptoms, patients with suspected Zika virus infections also should be evaluated and managed for possible dengue or chikungunya virus infection. Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided until dengue can be ruled out to reduce the risk of hemorrhage.
Few reports of severe disease: Guillain-Barre, meningoencephalitis, autoimmune complications. However, there have been cases of Guillain-Barre syndrome reported in patients following suspected Zika virus infection. 74 patients in the French Polynesia outbreak had presented neurological syndromes or auto-­immune syndromes after the manifestation of symptoms consistent with Zika virus infection.
In July 2015, Brazil reported the detection of patients with neurological syndromes who had recent history of Zika virus infection in the state of Bahia. There were 76 patients with neurological syndromes identified, of which 42 (55%) were confirmed as GBS. Among the confirmed GBS, 26 (62%) had a history of symptoms consistent with Zika virus infection. Now they are up to 121 suspected cases. In January 2016, El Salvador reported the detection of an unusual increase of GBS since early December On average, El Salvador records 14 cases of GBS per month (169 cases per year), however, between 1 December 2015 and 6 January 2016 there were 46 GBS recorded, of which 2 died.
Another flavivirus, dengue virus:
Perinatal DENV transmission can occur, and peripartum maternal infection may increase the likelihood of symptomatic infection in the newborn. Dengue can have harmful effects that include death of the unborn baby, low birth weight, and premature birth. DENV may also be transmitted through breast milk.
Based on the typical clinical features, the differential diagnosis for Zika virus infection is broad. In addition to dengue, other considerations include leptospirosis, malaria, rickettsia, group A streptococcus, rubella, measles, and parvovirus, enterovirus, adenovirus, and alphavirus infections (e.g., Chikungunya).
Perinatal DENV transmission can occur, and peripartum maternal infection may increase the likelihood of symptomatic infection in the newborn. Dengue can have harmful effects that include death of the unborn baby, low birth weight, and premature birth. DENV may also be transmitted through breast milk. Most CHIKV infections that occur during pregnancy will not result in the virus being transmitted to the fetus. However, when intrapartum transmission occurs, it can result in complications for the baby, including neurologic disease, hemorrhagic symptoms, and myocardial disease. There are also rare reports of spontaneous abortions after maternal CHIKV infection.

8. Birth Defects Linked to Zika
Microcephaly (decreased brain tissue)
Calcium deposits
Excess fluid
Absent or poorly formed brain structures
Abnormal eye development
Fetal Brain Disruption Sequence
Many other adverse outcomes
The associated adverse outcomes are many:
Hearing impairment; seizures; swallowing impairment; hypertonicity; contractures; severe irritability; developmental delay; growth abnormalities
The Florida Birth Defects Registry reports that the rate of microcephaly in Florida is 6.8 cases per 10,000 live births, which is equal to ~150 cases per year in FL residents.

9. Guillain-Barré Syndrome (GBS)
Guillain–Barré syndrome (GBS) is a rapid-onset muscle weakness caused by the immune system damaging the peripheral nervous system.
This autoimmune disease is caused by the body's immune system mistakenly attacking the peripheral nerves and damaging their myelin insulation.
Many people with Guillain–Barré syndrome have experienced the signs and symptoms of an infection in the 3–6 weeks prior to the onset of the neurological symptoms. This may consist of upper respiratory tract infection (rhinitis, sore throat) or diarrhea. 30% - Campy infection, 10% cytomegalovirus, other infections (1976 swine flu vaccine). There appears to also be a link to Zika infection.
Rare (1-2 per 100,000), sudden onset. Can be life-threatening (1 of 20 cases are fatal)
Rx: supportive

10. Suspect Zika Infection?
Infection with Zika should be suspected in:
All persons, including pregnant women, with two or more of the following signs/symptoms: fever, maculopapular rash, arthralgia or conjunctivitis (GBS could follow) and a history of travel to an area with Zika virus activity in the two weeks prior to illness onset
Mother of an infant or fetus with microcephaly or intracranial calcifications or other abnormalities, or poor fetal outcome diagnosed after the first trimester and history of travel to an area with Zika virus activity during pregnancy (Testing of both the mother and infant is recommended)

11. Suspect Zika Infection?
Infants of symptomatic or asymptomatic pregnant women who traveled to an area reporting Zika virus activity while pregnant (testing of both mother and infant is recommended)
Suspect local cases in a county/area with no reported local Zika virus infections and three or more of the following signs/symptoms: fever, maculopapular rash, arthralgia or conjunctivitis
Suspected Zika virus associated GBS cases

12. Florida Case Example 1 Female, early 40s Office visit on 1/26/2016
CC: red eyes, hives generalized, pain fingers (joints), fatigue
Travel history (Haiti) for two weeks (1/11 – 1/25)
Rash started on 1/22 resolved before (mild pruritus), arthralgia 3 days, fatigue and malaise
Recalls mosquito bites while overseas
Physical unremarkable
Laboratories
ZIKAV PCR/RNA Amplification (serum) Negative
ZIKAV PCR/RNA Amplification (urine) Positive
DENGUE FEVER ABS, IGG = (H)
Zika infections may be difficult to distinguish from other infections among travelers
Based on the typical clinical features, the differential diagnosis for Zika virus infection is broad. In addition to dengue, other considerations include leptospirosis, malaria, rickettsia, group A streptococcus, rubella, measles, and parvovirus, enterovirus, adenovirus, and Chikungunya infections.
Preliminary diagnosis is based on thorough evaluation of the patient’s clinical features, places and dates of travel, and activities.
Laboratory diagnosis is accomplished by testing serum, urine, and saliva to detect virus or virus-specific immunoglobulin M and neutralizing antibodies.

13. Florida Case Example 2 Female, late 50s Office visit on 2/2/2016
CC: fever, joint pain, headache, nausea, and rash (onset 1/30/16)
Travel history to PR (returning 1/29/2016)
Family member in PR diagnosed with Zika (Dx on 1/25/16?)
No information on physical
Laboratories
ZIKAV PCR/RNA Amplification (serum) Equivocal
ZIKAV PCR/RNA Amplification (urine) Positive
Zika infections may be difficult to distinguish from other infections among travelers
Based on the typical clinical features, the differential diagnosis for Zika virus infection is broad. In addition to dengue, other considerations include leptospirosis, malaria, rickettsia, group A streptococcus, rubella, measles, and parvovirus, enterovirus, adenovirus, and Chikungunya infections.
Preliminary diagnosis is based on thorough evaluation of the patient’s clinical features, places and dates of travel, and activities.
Laboratory diagnosis is generally accomplished by testing serum, urine, and saliva to detect virus or virus-specific immunoglobulin M and neutralizing antibodies.

14. Countries & Territories with Active Zika Transmission
Americas
Anguilla
Antigua and Barbuda
Argentina
Aruba
The Bahamas
Barbados
Belize
Bolivia
Bonaire
Brazil
British Virgin Islands
Cayman Islands
Colombia
Commonwealth of Puerto Rico, US territory
Costa Rica
Cuba
Curacao
Dominica
Dominican Republic
Ecuador
El Salvador
French Guiana
Grenada
Guadeloupe
Guatemala
Guyana
Haiti
Honduras
Jamaica
Martinique
Mexico
Nicaragua
Panama
Paraguay
Peru
Saba
Saint Barthélemy
Saint Lucia
Saint Martin
Saint Vincent and the Grenadines
Sint Eustatius
Sint Maarten
St. Kitts and Nevis
Suriname
Trinidad and Tobago
Turks and Caicos
United States
U.S. Virgin Islands
Venezuela
Oceania/Pacific Islands
American Samoa
Fiji
Kosrae, Federated States of Micronesia
Marshall Islands
New Caledonia
Papua New Guinea
Samoa
Tonga
Africa
Cape Verde
Asia
Singapore
Source: CDC, October 26, 2016

15. Current Status United States Florida (as of Oct.31)
183 non-travel related Zika cases
United States
3, 951 travel-associated cases (10/26/16 CDC)
US Territories
28, 723 locally acquired cases in US Territories (10/26/16 CDC)
As of Oct 20, 2016 for US numbers (CDC Arbonet)
Florida: Location of pregnant cases is not provided
US: 33 sexually transmitted, 13 GBS
Registry: 953 pregnant – any lab evidence, 23 liveborn with birth defects, 5 pregnancy losses with birth defects
US territories: 43 GBS; 98% of local cases are in PR
Registry: 2,027 pregnant

16. Zika Travel-Related Cases by County, Florida October 31, 2016
Infection Type
Infection Count
Travel-Related   Infections of Zika: 771
Non-Travel   Related Infections of Zika: 183
Infections Involving Pregnant Women: 124
Out of State Cases (not Florida Residents): 19
Undetermined: 6
Total: 1,103
Total travel related cases not involving pregnant women
771
Cases involving pregnant women
124

17. Miami-Dade situation
DOH continues door-to-door outreach and targeted testing in Miami-Dade county and mosquito abatement and reduction activities are also taking place around the locations that are being investigated. (as of 10/31/16)
DOH believes ongoing transmission is only taking place within the identified areas in South Beach and North Miami Beach in Miami-Dade County
The department is currently conducting 12 investigations, and has closed 33 investigations.
If investigations reveal additional areas of active transmission, the department will announce a defined area of concern.

18. CDC Health Advisory (10/20/2016)
Pregnant women
Postpone travel to Miami-Dade County
Be tested for Zika if
Has an epidemiologic link* to Miami-Dade Co since August 1, 2016
Has an epidemiological link* to Miami Beach since July 14, 2016
Women and men planning to conceive
Avoid travel to areas with active transmission
Postpone conception based on CDC recommendations
If you do not receive notifications from the Health Dept, please provide use with our .
*Lived in, traveled to, or had unprotected sex with someone who lived in
or traveled to the designated.

19. Emergency Rules Noticed
Noticed February 5, 2016
64DER16-1 (64D-3.029) Diseases or Conditions to be Reported
Requires immediate reporting to DOH of suspected or confirmed cases of the Zika virus by physicians, hospitals, and laboratories. Reporting should occur immediately as soon as infection is suspected but does not need to occur after hours.
Reporting should occur upon initial suspicion of infection (prior to testing) to ensure effective mosquito control efforts can begin as soon as possible, to reduce the possibility of local transmission.
Issued 5 Feb, 2016
Relates to Chapter 64D-3, Florida Administrative Code
Hospitals and physicians should report to their CHD in a manner similar to other reportable conditions

20. State and Local Actions
Executive Order Number 16-29
Directs State Health Officer (SHO) and Surgeon General to declare Public Health Emergency in counties with imported cases
Directs meetings be convened by the County Health Officer in the impacted counties to discuss mosquito control best practices and outreach to communities with high risk or vulnerable populations
County Health Officers for affected counties develop outreach program for local medical professionals to increase awareness and access to diagnostic tools

21. Response to Zika Virus Communication Surveillance Lab testing
Vector control
Outreach to pregnant women
Blood supply safety
Communication – key to the response! PSAs, outreach to municipalities, outreach to vulnerable populations (preg women), provide clinical and reporting guidance to providers.
Surveillance – increase HCP awareness, testing and reporting
Lab testing – coordinate with HCPs to test suspected cases
Vector control – coordinate with MCD for surveillance around possible cases; conduct joint public outreach
Outreach to pregnant women – targeted outreach and info to OB/GYNs
Blood supply safety – locally: notify about local cases
TTX with community partners to education and prepare – 7/6, f/u communications workgroup meeting 8/31; existing dengue/chik/zika response plan

22. Outreach to medical providers (especially OB/GYNs)
Forward clinical & reporting guidance / provide outreach materials for patients
Outreach to the public
Provide mosquito bite prevention info, PSAs to County, municipalities to post
At risk populations: Information distributed through HD, TCCH

23. Zika Testing Commercial testing is available through Quest & LabCorp
Criteria for testing
Possible exposure (travel or sexual) AND 2 or more of the following: (fever, maculopapular rash, arthralgia, conjunctivitis)
Any pregnant woman with possible exposure (travel or sexual) regardless of symptoms
Any person with 3 of the above signs/symptoms with no travel (suspected local case)
Patients meeting the above criteria who are uninsured can be tested through the Health Department at no cost.
Pregnant women without possible exposure who insist on testing after counseling, and who are uninsured can be tested through the Health Department
To ensure you are updated on available testing for Zika virus, this information is being sent broadly to health care providers in Indian River County.
Both LabCorp and Quest now have the capability of performing both PCR and IgM antibody testing for Zika virus infection.
For patients suspected of Zika virus infection, and meeting the criteria for testing:
Complete the attached questionnaire, and fax to Indian River County Health Department at the same business day.
Order testing through commercial laboratories as you would other tests (no need to obtain prior approval from the Health Department).
Criteria for Zika Testing:
Has traveled to an area or country with Zika virus transmission ( OR  Recent travel by a sex partner to an area with Zika virus transmission
AND
Has two or more of the following signs/symptoms: fever, maculopapular rash, arthralgia or conjunctivitis)
Any Pregnant woman with the possible exposure (travel or sexual) at any time during her pregnancy, regardless of symptoms 
Any person with three or more of the following signs/symptoms: fever, maculopapular rash, arthralgia or conjunctivitis with no travel (suspected local case)
Patients meeting the above criteria for testing, and who cannot obtain testing through commercial labs (e.g., are uninsured or underinsured) can be tested through the Health Department at no cost.  
Pregnant women without possible exposure to Zika, but who insist on testing after counseling, and who cannot obtain testing through commercial labs (e.g., uninsured or underinsured) can be tested through the Health Department.
NOTE: Contact the Health Department Epidemiology Program at to provide patient information prior to referring patients for Zika testing.
For the latest information on Zika Virus, please see the DOH website at:
Please contact us at or with any questions or concerns.

24. Reporting suspected cases of Zika virus infection
Complete Zika risk factor questionnaire
Fax to DOH – Indian River at
Order testing through a commercial laboratory
We sent this questionnaire out broadly to providers at the end of September.

25. Aedes aegypti
“Yellow fever mosquito”
Only two Florida mosquito species can transmit Zika, dengue or chikungunya viruses!
Virus transmission cycle
Aedes albopictus
“Asian tiger mosquito””

26. Basic Mosquito Life Cycle
Blood-feeding female
Emerging adult
Eggs
Basic Mosquito
Life Cycle
Larva
Pupa

27. Mosquitoes that transmit Zika, dengue and chikungunya viruses
come from water sources like this…

28. or like this…

29. Artificial and natural containers are the only sources of concern.
Mosquitoes that transmit Zika, dengue and chikungunya viruses never lay their eggs in “standing water” on the ground!
Water in ditches, marshes, ponds or canals is irrelevant to Zika, dengue, or chikungunya transmission
Artificial and natural containers are the only sources of concern.
Messaging problem!!
Containers vs. ‘standing water’

30. Control of mosquitoes transmitting Zika, dengue or chikungunya viruses
Characteristics of mosquitoes transmitting Zika, dengue or chikungunya viruses
Aggressive day-time biters
Aquatic stages in artificial containers, bromeliads, treeholes
Short flight-range; adults stay close to hatching site
Control of mosquitoes transmitting Zika, dengue or chikungunya viruses
Control of adults is a problem (these mosquitoes are not flying at night when spraying is most common)
Targeted spraying around infested residences can help
Elimination of container habitats around homes and work places is the only truly effective control measure!