Zika Update Laurie Welton D O Miranda Hawker

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

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

Transmission �Mosquito bite (Aedes aegypti, Aedes albopictus) �Sexual transmission �Transmission in the womb and at the time of birth �Blood transfusion

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 4

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: 5 �Fever (often low-grade) �Myalgia �Maculopapular rash �Headache �Arthralgia �Retro-orbital pain �Conjunctivitis �Vomiting

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

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 7

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

Guillain-Barré Syndrome (GBS)

Suspect Zika Infection? Infection with Zika should be suspected in: 1 0 1. 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 2. 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)

Suspect Zika Infection? 1 1 3. 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) 4. 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 5. Suspected Zika virus associated GBS cases

Florida Case Example 1 � Female, early 40 s � 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 = 11. 46 (H) 1 2

Florida Case Example 2 �Female, late 50 s �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 1 3

Countries & Territories with Active Zika Transmission Source: CDC, October 26, 2016

Current Status �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)

Zika Travel-Related Cases by County, Florida October 31, 2016 Total travel related cases not 771 involving pregnant women Cases involving pregnant 124 women

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 *Lived in, traveled to, or had unprotected sex with someone who lived in or traveled to the designated.

Emergency Rules Noticed �Noticed February 5, 2016 � 64 DER 16 -1 (64 D-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. 1 9

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 2 0

Response to Zika Virus �Communication �Surveillance �Lab testing �Vector control �Outreach to pregnant women �Blood supply safety

Zika Testing �Commercial testing is available through Quest & Lab. Corp �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

Reporting suspected cases of Zika virus infection �Complete Zika risk factor questionnaire �Fax to DOH – Indian River at 772 -794 -7482 �Order testing through a commercial laboratory

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

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

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

or like this…

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.

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!