Texas Department of Health

Baby Born in Texas with Microcephaly Linked to Zika

News Release

July 13, 2016

Lancet

“…Our findings raise the threat of a woman potentially becoming a chronic Zika virus carrier, with the female genital tract persistently expressing the virus RNA. …”

NIH

Researchers supported by the National Institutes of Health will monitor potential Zika virus exposure among a subset of athletes, coaches and other U.S. Olympic Committee (USOC) staff attending the 2016 Summer Olympics and Paralympics in Brazil. The study, funded by NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and led by Carrie L. Byington, M.D., from the University of Utah, Salt Lake City, aims to improve understanding of how the virus persists in the body and to identify potential factors that influence the course of infection.

“Zika virus infection poses many unknown risks, especially to those of reproductive age,” said Catherine Y. Spong, M.D., acting director of NICHD. “Monitoring the health and reproductive outcomes of members of the U.S. Olympic team offers a unique opportunity to answer important questions and help address an ongoing public health emergency.”

USOC established an Infectious Disease Advisory Group (IDAG), chaired by Dr. Byington, to help prepare the U.S. Olympic team for travel to Brazil, which is the epicenter of the Zika virus outbreak in the Americas. Dr. Byington proposed the project, which aims to enroll at least 1,000 men and women, in response to an NIH announcement designed to expedite review and funding for Zika-related research projects.

“We partnered with the USOC to improve knowledge of the dynamics of Zika infection, so that we can better protect the health of athletes and staff who will participate in the 2016 Games,” said Dr. Byington. “This ongoing relationship also opens avenues for long-term research that promises to benefit not only the Americas, but also other regions facing the emergence of the virus.”

The current study seeks to determine the incidence of Zika virus infection, identify potential risk factors for infection, detect where the virus persists in the body (blood, semen, vaginal secretions or saliva), evaluate how long the virus remains in these fluids, and study the reproductive outcomes of Zika-infected participants for up to one year.

To prepare, USOC and the University of Utah conducted a pilot study in March and April 2016. The study was fully enrolled in two days and included 150 participants. Notably, one-third of the pilot group indicated that they or their partner planned to become pregnant within 12 months of the Olympic Games.

Participants in the current study will complete health surveys and provide samples of bodily fluids for the detection of Zika and similar flaviviruses, such as dengue. Zika virus infection typically does not cause symptoms in adults, so routine sampling will detect asymptomatic infections and help shed light on symptomatic versus asymptomatic infections. Zika virus testing kits and training on how to use the tests will be provided by the U.S. Centers for Disease Control and Prevention.

Before traveling to Brazil, all USOC staff, including athletes and coaches, will be briefed on a number of items, including the Zika outbreak. IDAG will provide educational materials to athletes and staff and answer questions. During this time, the NIH-funded researchers will present the study and enroll as well as consent USOC staff who are interested in participating. Approximately 3,000 USOC staff members are expected to travel to Brazil. In addition, spouses or sexual partners who are traveling to Brazil may be eligible to participate.

The 2016 Summer Olympics will take place in Rio de Janeiro, from Aug. 5-21, 2016, and the Paralympic Games are scheduled for Sept. 7-18, 2016.

WHO

“…..They should start breastfeeding within one hour of birth, be exclusively breastfed for six months and have timely introduction of adequate, safe and properly fed complementary foods, while continuing breastfeeding up to two years of age or beyond…..In light of the evidence available, the benefits of breastfeeding for the infant and mother outweigh any potential risk of Zika virus transmission through breast milk…….”

LANCET

“…..Viral antigens were localized to glial cells and neurons and associated with microcalcifications in all three fatal cases with microcephaly. Antigens were also seen in chorionic villi of one of the first trimester placentas. Tissues from all five cases were positive for Zika virus RNA by RT-PCR, and sequence analyses showed highest identities with Zika virus strains isolated from Brazil during 2015……”

 

 

Lancet

This is an official
CDC HEALTH UPDATE
Distributed via the CDC Health Alert Network
June 21, 2016, 1140 EDT (11:40 AM EDT)
CDCHAN-00392
CDC Recommendations for Subsequent Zika IgM Antibody Testing
Summary
Testing for Zika virus infection using real-time reverse-transcription polymerase chain reaction (rRT-PCR)
molecular assays is now commercially available. When requesting Zika rRT-PCR testing from a
commercial laboratory, providers should be aware that commercial laboratories performing rRT-PCR
currently do not also offer Zika IgM enzyme-linked immunosorbent assay (ELISA) or confirmatory
serologic testing (plaque reduction neutralization test, or PRNT). Therefore, if possible, providers should
store a serum aliquot for subsequent Zika IgM ELISA testing if the rRT-PCR assay is negative. Otherwise,
collection of an additional serum sample may be necessary.
Recommendations
• rRT-PCR (molecular) testing should be performed for patients possibly exposed to Zika virus who
have symptoms consistent with Zika virus infection
• Providers who request molecular testing for Zika virus infection from a commercial testing
laboratory are advised to retain and store in a refrigerator (2-8°C) an aliquot of the patient’s
serum for subsequent Zika IgM ELISA testing if the rRT-PCR is negative
• For specimens that are rRT-PCR negative from the commercial laboratory and no stored serum
specimen is available, another serum specimen should be collected within 12 weeks of symptom
onset for Zika IgM ELISA testing
• Appropriate samples for molecular testing are serum samples collected <7 days and urine
samples collected <14 days after symptom onset. Urine should always be collected with a
patient-matched serum specimen.
Background
Molecular assays for detection of Zika virus RNA are now commercially available under Emergency Use
Authorizations (EUAs) issued by the Food and Drug Administration (FDA). CDC recommends molecular
testing using rRT-PCR for serum samples collected <7 days and urine samples collected <14 days after
symptom onset. A positive rRT-PCR test is confirmation of Zika virus infection. However, because of the
decline in the level of viremia over time and possible inaccuracy in reporting of dates of illness onset, a
negative rRT-PCR result does not exclude Zika virus infection. In such cases, CDC recommends
serologic testing by ELISA for Zika IgM antibody.
Currently, commercial laboratories that offer rRT-PCR testing do not provide Zika IgM ELISA testing with
PRNT confirmation and have no routine process to forward specimens to another testing laboratory.
Therefore, when requesting Zika rRT-PCR testing from a commercial laboratory, providers should retain
an aliquot of the serum for Zika IgM ELISA testing if the rRT-PCR testing is negative. Blood should be
collected and processed per routine guidelines (collected in a serum separator tube with serum aliquots
transferred to new vials), and one of the serum aliquots should be stored in a refrigerator (2-8°C) until it is
known if additional IgM testing is indicated. If a serum aliquot cannot be stored or is not available, but
further testing is indicated, a new blood sample should be collected. Serum samples for IgM testing
should be collected from patients within 12 weeks of symptom onset. Providers should contact their local
health department to discuss IgM testing of stored or newly collected serum from patients who are rRTPCR
negative.
For More Information
• Zika virus specimen collection:
http://www.cdc.gov/zika/hc-providers/body-fluids-collection-submission.html.
• Interim guidance for Zika virus testing of urine:
http://www.cdc.gov/mmwr/volumes/65/wr/mm6518e1.htm
The Centers for Disease Control and Prevention (CDC) protects people’s health and safety by preventing and
controlling diseases and injuries; enhances health decisions by providing credible information on critical health
issues; and promotes healthy living through strong partnerships with local, national, and international
organizations.
____________________________________________________________________________________
Categories of Health Alert Network messages:
Health Alert Requires immediate action or attention; highest level of importance
Health Advisory May not require immediate action; provides important information for a specific incident or situation
Health Update Unlikely to require immediate action; provides updated information regarding an incident or situation
HAN Info Service Does not require immediate action; provides general public health information
##This message was distributed to state and local health officers, state and local epidemiologists, state
and local laboratory directors, public information officers, epidemiologists, HAN coordinators, and clinician
organizations##

WHO

Brazil – Health Advice for Travellers to the 2016 Summer Olympic and Paralympic Games

21 June 2016

The XXXI Summer Olympic and Paralympic Games Rio de Janeiro 2016, Brazil, will take place from 5 to 21 August 2016 and from 7 to 18 September 2016 respectively. Five additional cities will be hosting matches of the Olympic football tournament – Belo Horizonte, Brasilia, Manaus, Salvador, and São Paulo.

The following recommendations are intended to advise national health authorities and health care providers about practices and measures for travellers visiting Brazil to stay safe and healthy.

Before departure, travellers should be advised about health risks in the areas they plan to visit and related preventive practices and measures to minimize the probability of acquiring diseases and of having accidents.

Travellers to Brazil should consult the travel advice issued by their national authorities.

Health authorities of Brazil provide health advice for visitors to Brazil on their website in portuguese (see list of websites below). Health services affiliated to the public Unified Health System of Brazil (Sistema Único de Saúde, SUS) are free of charge for all individuals, including visitors.

Vaccine preventable diseases

A medical consultation should be scheduled as early as possible before travel but at least 4–8 weeks before departure in order to allow sufficient time for immunization schedules to be completed for both routine vaccines and vaccines indicated according to the specific destinations. Even when departure is imminent, there is still time to provide both advice and some vaccines.

Routine vaccines

Travellers should be vaccinated according to their national immunization schedule, which will vary from one country to another. Routine immunization schedules, established by national authorities, include vaccination against diphtheria, pertussis, tetanus, polio, measles, hepatitis B, Haemophilus influenzae type b and, in many countries, additional diseases such as rubella, mumps, flu, yellow fever, human papillomavirus, and rotavirus and pneumococcal diseases.

Since July 2015, Brazil has interrupted measles transmission, following an outbreak associated with an imported case. As measles is still endemic or circulating in many countries, measles vaccinations should be up to date to prevent importation of the virus to Brazil. Similar considerations apply for rubella, which was eliminated from Brazil in 2009.

Wild poliovirus has been eliminated from Brazil since 1989. To prevent the re-introduction of polio into Brazil, travellers from countries where polio cases have recently occurred should be fully immunized.

For travellers at risk of serious complications of influenza, vaccination should be considered. WHO recommends seasonal influenza vaccination for pregnant women, the elderly, individuals with specific chronic medical conditions, children aged 6-59 months, and healthcare workers. Note that WHO advices pregnant women not to travel to the Olympics or any area where Zika virus is circulating. The influenza strain currently circulating in Brazil, A(H1N1)pdm09, is included in both the northern hemisphere 2015-2016 and the southern hemisphere 2016 vaccines. The Olympic and Paralympic Games will take place after the influenza season in Rio de Janeiro is expected to have peaked in June and July; however, there are regional variations and cases occur throughout the year in Brazil. At-risk travellers should ideally receive influenza vaccine at least two weeks prior to departure.

Travel-related vaccines

Depending on the specific travel itinerary, additional vaccines might be considered for some travelers. Unvaccinated travellers should be offered such vaccines in accordance to their national recommendations.:

• Hepatitis A: Brazil is an intermediate endemicity country and prone to hepatitis A outbreaks;
• Hepatitis B: The risk of contracting hepatitis B is likely to be low, except for travellers engaging in high risk behaviours such as tattoos and injecting drug use. Hepatitis B vaccine was introduced into the national immunization schedule in Brazil in 1998;
• Typhoid fever: The incidence of typhoid fever in Brazil is highest in the North and North-East, including Amazonas and Manaus which is hosting the Olympic football tournament;
• Rabies: The risk of rabies infection in Rio de Janeiro and the remaining five cities hosting the Olympic football tournament is negligible;
• Yellow fever: A single, lifetime dose of Yellow Fever vaccine is recommended for all travellers older than 9 months visiting areas at risk of yellow fever transmission. The vaccination should be conducted at least 10 days before departure. The vaccine confers lifelong protection. Vaccination is not recommended for travellers limiting their stay to the following cities hosting Olympic and Paralympic Games’ events: Rio de Janeiro, Salvador, São Paulo. Further international spread of the ongoing yellow fever outbreak in Angola could potentially require WHO to adjust these recommendations (see list of websites below for more information).

Mosquito-borne diseases

Personal protective measures

Although the risk of mosquito borne disease is lower during winter, travellers should still take personal protective measures to prevent mosquito bites. These include:

• Whenever possible, wearing clothes (preferably light-coloured) that cover as much of the body as possible during the day;
• Using repellents that contain DEET (diethyltoluamide), or IR 3535, or icaridin andare applied to exposed skin or to clothing and used in strict accordance with the label instructions, especially regarding the duration of protection and timing of re-application. If repellents and sunscreen are used together, sunscreen should be applied first and the repellent thereafter;
• Choosing sanitary accommodations with piped water and physical barriers such as proper window and door screens to prevent mosquitoes from entering rooms;
• Avoiding areas in cities and towns with no piped water and poor sanitation, which constitute ideal breeding grounds for mosquitoes.

Arboviruses transmitted by Aedes mosquitoes

In addition to yellow fever (see above vaccination requirements), mosquito-borne diseases transmitted by Aedes species mosquitoes include chikungunya, and dengue and Zika virus disease.

Dengue and chikungunya

Detailed information about dengue and chikungunya is available on the websites of Brazil’s Ministry of Health, WHO and PAHO/AMRO (see list of websites below). There is no vaccination for chikungunya. Dengue vaccination is not recommended for travellers.

Zika virus disease

Zika virus infection usually causes a mild disease, and many cases of Zika virus infection are asymptomatic. However, following an outbreak of Zika virus in Brazil in 2015 and its subsequent spread in the Americas, an unusual increase in serious neurological disorders was seen in the off-springs of pregnant women who had been infected, including cases of microcephaly and congenital neurological malformations. Cases of Guillain-Barré Syndrome (GBS), a rare but serious form of muscle weakness, were observed among adults. Based on a growing body of research, there is scientific consensus that Zika virus is a cause of microcephaly and Guillain-Barré syndrome. Zika virus is primarily spread by mosquitoes, though sexual transmission has increasingly been documented.

On the basis of current knowledge about Zika virus disease and its complications, the following is recommended to national health authorities and health care practitioners:

• To provide travellers to areas of ongoing Zika virus transmission, including Brazil, with up-to-date advice on appropriate measures to reduce the risk of becoming infected, including by preventing mosquito bites and practicing safe sex (e.g. use condoms correctly and consistently); and on the potential consequences and complications of infection, especially for women who are pregnant or planning a pregnancy; non-barrier forms of birth control will not protect against sexual transmission of Zika virus infection;
• To advise pregnant women not to travel to areas of ongoing Zika virus outbreaks, including Brazil;
• To advise women who inadvertently become pregnant or discover they are pregnant in or shortly after returning from Brazil, and/or other areas with ongoing Zika virus transmission, to contact their health care providers;
• To advise pregnant women whose sexual partners live in or travel to areas with Zika virus outbreaks to ensure safe sexual practices or abstain from sex for the duration of their pregnancy;
• To advise travellers to practice safe sex or abstain from sex during their stay in Brazil, and/or other areas with ongoing Zika virus transmission, and for at least eight weeks after their return. If men experience symptoms of Zika virus disease, they should adopt safer sex practices or abstain from sex for at least six months;
• To advise travellers returning from Brazil, and/or other areas with ongoing Zika virus transmission, not to donate blood for at least four weeks after departure from the area¹;
• To advise health care practitioners to be on alert for Zika virus disease in travellers returning from Brazil and/or other areas with ongoing Zika virus transmission;
• National authorities should provide health care practitioners with clear guidance on how to refer travellers with suspected Zika virus infection for suitable clinical management and testing where appropriate.

Malaria (transmitted by Anopheles mosquito)

The risk of malaria transmission is negligible or non-existent except in the administrative region of Amazonas, corresponding to the Northern states of Brazil. This includes the city of Manaus which is hosting some of the Olympic football matches.

Plasmodium falciparum infections account for approximately 15% of malaria cases in Brazil. In malaria-affected areas, in addition to mosquito bite prevention (including use of repellents and sleeping under an insecticide treated mosquito net), chemoprophylaxis with atovaquone–proguanil, or doxycycline, or mefloquine should be considered and selected according to reported side-effects and contraindications. Alternatively, for travel to rural areas with low risk of malaria infection, mosquito bite prevention can be combined with stand-by emergency treatment (SBET).

Based on the risk assessment by Brazilian health authorities, the national guidelines do not include recommendations on malaria chemoprophylaxis. Therefore, the access to these drugs while in Brazil will be limited and antimalarial drugs should be purchased before travelling. Travellers who become ill with a fever while traveling in a malaria-risk area within Brazil should seek immediate medical attention (see list of websites below for diagnostic and treatment health centres). Travellers who become ill with a fever for up to one year after their travel should inform their health care practitioners about their travel history. There is no vaccination recommended for malaria.

Sexually Transmitted Infections (other than Zika virus infection)

The risk of infection with HIV, syphilis, gonorrhoea, chlamydia, herpes, Hepatitis B virus (HBV), and other sexually transmitted infections is primarily limited to travellers engaging in sexual risk behaviours, especially unprotected sex and particularly with sex workers and among men who have sex with men and injecting drug users. Therefore, the adoption of safe sex practices, and specifically consistent and correct condom use, is recommended. Brazilian authorities launched a health promotion and prevention campaign in relation with sexually transmitted diseases, AIDS and hepatitis (see list of websites below).

Food and water safety

As gastrointestinal infections can be common in Brazil, health care practitioners should advise travellers to take precautions to avoid illnesses caused by unsafe food and drink. These precautions include: frequent hand washing and always before handling and consuming food; making sure that food has been thoroughly cooked and remains steaming hot; choosing safe water (e.g. bottled water or, if in doubt, water vigorously boiled); avoiding any uncooked food, apart from fruits and vegetables that can be peeled or shelled; avoiding foods at buffets, markets, restaurants and street vendors if they are not kept hot or refrigerated/on ice.

The quality of recreational water in Rio de Janeiro, including in the venues hosting Olympic and Paralympic Games events, has been suboptimal because of sewage contamination. While corrective actions are being taken, travellers should follow the advice issued by competent local authorities (see list of websites below).

Other infectious disease risks

The risk for travellers of acquiring airborne infections, such as tuberculosis and meningitis is limited, unless they stay in overcrowded indoor spaces.

Travellers to the Belo Horizonte area should be aware of the risk of acquiring tickborne Brazilian spotted fever, caused by the bacterium Rickettsia rickettsii, and that might result from contact with an infected rodent called capybara.

Travellers to the Salvador area should be aware of the risk of acquiring leptospirosis, caused by the Leptospira bacterium, which might result from skin and mucosal exposure to water and soil contaminated with the urine of infected animals. A wide range of animals can carry the bacterium.

The risk of leishmaniasis (both cutaneous and visceral), schistosomiasis, lymphatic filariasis, and other neglected tropical diseases is mostly associated with rural areas of the north-eastern region of Brazil.

Safety and security and other health risks

Crime, including theft and violent crime, does occur in Brazil. Travellers should be advised to exercise caution and only use authorized airport taxis or shuttle buses, not travel alone at night, avoid questionable areas, and travel with a companion.

Traffic accidents and injuries, mostly caused by motor vehicle crashes, are the leading causes of death among travellers under the age of 55 years. After heavy rainfall, flash floods and landslides, especially in urban areas, have been a frequent cause of injuries and other emergencies.

Travellers should be aware of the presence of poisonous animals, such as scorpions and snakes, and take precautions to avoid any contact with such animals. Local health authorities can provide more detailed information about specific areas of risk.

It is good practice for health care practitioners to systematically collect the travel history from their patients, taking into account that some travel associated infections have a long incubation period.

List of websites for further information

• National travel and health advice websites
  • http://www.who.int/ith/links/national_links/en/
• Health advice for travellers to Brazil on Brazil’s Ministry of Health website
  • http://portalsaude.saude.gov.br/index.php?option=com_content&view=article&id=9643#preparando3
• Information on global polio vaccination requirements
  • http://www.polioeradication.org/
• Information on influenza in Brazil (in Portuguese)
  • http://portalsaude.saude.gov.br/index.php/situacao-epidemiologica-dados-influenza
• Information on rabies in Brazil
  • http://saude.sp.gov.br/resources/instituto-pasteur/pdf/wrd2015/situacaodaraivanobrasil-eduardopachecodecaldas.pdf
• Information on yellow fever vaccination requirements
  • http://who.int/emergencies/yellow-fever/en/
  • http://www.who.int/ith/2015-ith-county-list.pdf?ua=1
  • http://gamapserver.who.int/mapLibrary/Files/Maps/
  ITH_YF_vaccination_americas.png?ua=1
• Information on dengue fever
  • http://www.who.int/mediacentre/factsheets/fs117/en/
  • http://www.paho.org/hq/index.php?option=com_topics&view=article&id=1&Itemid=40734&lang=en
• Information on Chikungunya
  • http://www.who.int/mediacentre/factsheets/fs327/en/
  • http://www.paho.org/hq/index.php?option=com_topics&view=article&id=343&Itemid=40931&lang=en
• Information on Zika virus disease
  • http://www.who.int/emergencies/zika-virus/en/
  • http://www.paho.org/hq/index.php?option=com_content&view=article&id=11585&Itemid=41688&lang=en
  • http://www.paho.org/hq/index.php?option=com_content&view=article&id=11603:countries-territories-zika-autochthonous-transmission-americas&Itemid=41696&lang=en
  • http://portalsaude.saude.gov.br/index.php/situacao-epidemiologica-dados-zika
  • http://combateaedes.saude.gov.br/ and
  • http://portalsaude.saude.gov.br/index.php/o-ministerio/principal/secretarias/svs/zika
  • http://www.paho.org/hq/index.php?option=com_content&view=article&id=11585&Itemid=41688&lang=en
  and at http://www.who.int/emergencies/zika-virus/en/
• Information on Malaria
  • http://portalsaude.saude.gov.br/images/jpg/2015/junho/24/Mapa-de-risco-2014.jpg
  • http://bvsms.saude.gov.br/bvs/publicacoes/guia_prevencao_malaria_
  viajantes.pdf
  • http://www.who.int/ith/2016-ith-county-list.pdf?ua=1
  • http://portalsaude.saude.gov.br/index.php/o-ministerio/principal/leia-mais-o-ministerio/662-secretaria-svs/vigilancia-de-a-a-z/malaria/12193-centros-para-diagnostico-e-tratamento
• Information about the health promotion campaign launched by the Brazilian Government on the occasion of the Olympic and Paralympic Games
  • http://www.aids.gov.br/noticia/2016/ddahv-e-unaids-anunciam-campanha-em-parceria-para-os-jogos-rio-2016
• Information on water and sanitation
  • http://www.who.int/water_sanitation_health/bathing/statement-rio-water-quality/en/

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¹ National health authorities/national blood services should put in place and implement appropriate procedures to reduce the risk of transmission of mosquito-borne infections through transfusion, including temporarily deferring donors who are at high risk of infection due to international travel.

MMWR

Lee CT, Vora NM, Bajwa W, et al.

Zika Virus Surveillance and Preparedness — New York City, 2015–2016.

MMWR Morb Mortal Wkly Rep. ePub: 21 June 2016.

DOI: http://dx.doi.org/10.15585/mmwr.mm6524e3.

Number of persons born in Mexico, the Caribbean, Central America, and countries in South America with active Zika virus transmission, by U.S. Census tract of residence — New York City, January–February 2016

Zika Vaccine