ThePoten)alIntroduc)onofZikavirusintotheUS–Implica)onsforPublicHealthandBloodSafety–
LessonsLearnedfromOtherArboviruses
SusanL.Stramer,PhDVP,Scien)ficAffairs
ThrombosisandHemostasisSocie)esofNorthAmerica
2016Summit,April15
1
NothingtoDisclose
CurrentArboviralThreatstotheCon)nentalUS
• Dengue:1/3ofworldpopula8onatrisk,30-foldincreasein50yrs• Chikungunya:Re-emergedintheAmericaslate2013;≈1.7Mcases• Zika:evidenceofpastorcurrenttransmissionacrossAfrica,Asia,W.Pacific;confirmedinBrazilMay2015;nowass’dwithmicrocephalyandGuillain-Barrésyndrome;62countriestotalsince2007;33countriesintheAmericasto2016
Dengueriskmaps
3
DengueIncidenceisRapidlyIncreasingintheAmericas
0
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1000000
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2000000
25000001980
1982
1984
1986
1988
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1992
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1998
2000
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Num
berC
ases
Year
Source:PanAmericanHealthOrganiza8on(PAHO) 4
5
6
7
8
9
27,084suspectedcases
FrenchWestIndes1Dec2013–24Apr2015Guadeloupe:81,350cases
PuertoRico
Mar)nique:72,520cases
PuertoRico:31,433cases
10
PuertoRico,PassiveDengueSurveillanceSystem
199917
Oct28,
SpreadofZIKAVirus(ZIKV)
11
SpreadoftheZIKV• 1947:firstdetectedinUganda,Africa
• 1947to2007:14humaninfec)onswerereported(AfricaandAsia)
• 2007:FirstoutbreakinYap,FederatedStatesofMicronesia,Pacific
• 2007to2013:1infec)oninPhilippinesfromretrospec)vestudy
• 2013to2014:AlargeoutbreakoccurredinFrenchPolynesiawith ~32,000symptoma)ccases,11%ofthepopula)on
2.8%rateofRNAinblooddonors,11/42(26%)reportedPDI,viralloads10^3-10^7copies/mL
• 2014:SpreadthroughouttheSouthPacific
• 2015:SpreadtoSouthAmerica(BrazilandColumbia)
Jones KE, Patel NG, Levy MA. et al. Nature 2008 12
ZIKVpublica)ons:1952-2009(firstdescrip8ontofirstoutbreakinYap)=252010-2015632016225
13
Petersenetal.,ZikaVirus;NEJMMarch30,2016
Endemic
14
ZIKVVectors:AedesMosquitoes
• Aedes(stegomyia)speciesmosquitoes– Ae.aegyp.mostefficientvectorforhumans
– Ae.albopictusspreadinmoretemperatezones
• Alsotransmitdengueandchikungunyaviruses
• Layeggsindomes8cwater-holdingcontainers;toleratedrying
• Liveinandaroundhouseholds• Aggressiveday8mebiters;canalsobiteatnight
• Mul8plehumansbibenforasinglebloodmeal
15
ArbovirusComparisonCharacteris)c Dengue Chikungunya Zika
Virusfamily Flaviviridae Togaviridae Flaviviridae
Virusgenus Flavivirus Alphavirus Flavivirus
Serotypes 4 1 1
Genotypes Mul)pleperserotype 3 2
Vectors Aedesaegyp*Aedesalbopictus
Aedesaegyp*Aedesalbopictus
Aedesaegyp*Aedesalbopictus
Symptoms/illness
Acutefebrileillness
Acutefebrileillness
Acutefebrileillness
Symptoma)c:Asymptoma)c 25:75 75:25 25:75
Illnessoutcome Severedengue–plasmaleakage
Rarelysevere,Arthralgias
Rarelysevere,Microcephaly,Guillian-Barré 16
ZIKV(forAABBFactSheetPriorto2013)
• Mosquito-borneviraldisease• Zikarecognizedin1947intheZikaforestinUgandaintherhesus
macaques;AfricanlineageandAsianlineage• Usuallymild,las8ngfor2-7days• Mainsymptomsinclude:
– Low-gradefever(<38.5°C)– Transientarthri8s/arthralgiawithpossiblejointswellingmainlyinthe
smallerjointsofthehandsandfeet• Maculopapularrashojenspreadingfromthefacetothebody• Conjunc8valhyperemiaorbilateralnon-purulentconjunc8vi8s• Generalnon-specificsymptomssuchasmyalgia,astheniaandheadaches• Incuba8onperiod3-12days• Infec8onmaygounrecognizedorbemisdiagnosedasdengue,
chikungunyaorotherviralinfec8onsgivingfeverandrash.Asymptoma8cinfec8onsaretherule,≈75%
• Diseaseisusuallymild 17
ClinicalFeatures:ZIKVComparedtoDengue(DENV)andChikungunya(CHIKV)
Features ZIKV DENV CHIKV
Fever + +++ +++Rash +++ + ++Conjunc)vi)s ++ - -Arthralgia ++ + +++Myalgia + ++ +Headache + ++ ++Hemorrhage - ++ -Shock - + -
18
ZIKVandGuillain-BarréSyndrome,2013-2014• ZIKVinfec8onhistoricallywasthoughttoproduceamilddisease• WiththelargeoutbreakinFrenchPolynesia(~32,000cases),ariseincasesof
Guillian-BarréSyndromewasobserved• Pastincidencewasabout5casesperyear• DuringtheZIKVoutbreak,42casesin6months(20Xincrease)
• AllhadZIKVneutralizingan8body• 15admibedtointensivecareunits• FrenchPolynesiaonlyhas270,000inhabitants!
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W1 W3 W5 W7 W9 W11 W13 W15 W17 W19 W21
GBS
cases
ZIKV
cases
WeeksCourtesyofD.Musso
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ZikaandGuillain-BarréSyndrome
OR>34betweenGBSandpriorZIKVinfec8onNow13countries/territoriesreportanincreaseinGBS
20
ZIKVGenomefromtheAmericasAsiangenotypemostcloselyrelatedtotheFrenchPolynesian2013strainPa8entwithExanthemaandconjunc8vi8s
Enfissietal.Jan62016TheLancet
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ZIKV-AssociatedMicrocephalytoDec2015
• Ane8ologicroleforZIKVhasnotbeenproven,but…..• ZIKVRNAhasbeenisolatedfromatleast3casesinBrazil,2fromamnio8cfluidoffetuseswithmicrocephalyonultrasoundandonefrombloodand8ssueofababythatdiedatbirth
• 4mothersofmalformedbabiesinFrenchPolynesiahavebeenfoundtohaveIgGan8-ZIKV,buthavenohistoryofcompa8bleillness
• Es8matedrisk1:100infirsttrimester• Diagnos8ctes8ngrequiredtodifferen8ateDENV,CHIKVandZIKV– Note:othercausesincludeinfec8ons(toxo,rubella,herpes,syphilis,CMV,HIV),toxins,alcohol,gene8cabnormali8esandseveremalnutri8onduringpregnancy 22
ZIKADiseaseinBrazil(Dec82015)1,761reportedin422municipali)esin14Brazilianstateswith19fatali)es
1.PossibleZIKVinfec8onduringpregnancy.2.FetalCNSchangeswithpossiblyrelatedZIKVinfec8onduringpregnancy.3.Miscarriageduetopossibleassocia8onwithZIKVinfec8onduringpregnancy.4.S8llbornduetopossibleinfec8onduringpregnancyZIKV.5.Newbornlivewithmicrocephalypossiblyassociatedwithinfec8onZIKVduringpregnancy.
ProtocolfromtheSecretaryofHealthSurveillanceremonitoringforZIKV-associatedmicrocephalyandfetalmalforma)ons:
23
RatesofMicrocephalyOverTime:theAmericasandtheCaribbean
20-foldincreaseinratesofmicrocephalyintheAmericasandCaribbeanfrom2010-2014and2015
Source:PanAmericanHealthOrganiza)on,Epidemiologicalupdate,17January2016
MicrocephalyratesbystateinBrazil(casesper1,000livebirths)
EpiWeek522015
Countrylimits
BrazilStateBoundaries
0.1-1.01.1-15.015.1-30.030.1-45.0
45.1-88.6
Countries
CountrieswithZikaconfirmedcases
UpdatedasofEpidemiologicalWeek52(December27,2015–January2,2016)
DataSource:ReportedfromtheIHRNa8onalFocalPointsandthroughtheMinistryofHealthwebsites.
MapProduc)on:PAHO-WHOADCHAIRARO
24
ZIKVinBrazil• Es8matednumberofinfec8ons– 498,000to1,482,000
• 27/27stateshavereportedcasesofmicrocephaly
• 2982reportedcasesin2015• 2908reportedcasesin2016(thruMarch27)– Previously147-175(2010-2014)
• 907confirmedplus4293underinves8ga8on
• 46confirmeddeaths– 130underinves8ga8on
25
Feb102016
PregnantfemalereturnsfromRioGrandedoNortestate;weeks20-28normalpregnancyDuring13thweek,shehadhighfever,musculoskeletalandretroorbitalpain,itchingandrashAbnormali8esatweek32=>pregnancyterminated
intrauterinegrowthretarda8on,microcephaly,brainstructuresblurred,extremelycalcified(includingtheplacenta),severebraindiseasenoothercausesofmicrocephaly(family)
ZIKVRNAbyRT-PCR6.5x10^7copies/mgbrain8ssue;allotherflavivirusesandothervirusesnegFullgenomesequencedfromthefetalbrain;densepar8clesresemblingvirusand
envelopedstructuresresemblingreplica8vecomplexesalsoobserved99.7%gene8crelatednesstoFrenchPolynesia2013strainandSaoPaulo2015strainNopresenceofZIKVandnopathologicalfindingsdetectedinanyotherfetalorgans=>Strongneurotropismofthevirus
26
27
ZikavirusintheAmericas:Earlyepidemiologicalandgene)cfindings–
Casesappeared2yearsa=eritsintroduc*onintoBrazil
by Nuno Rodrigues Faria, Raimunda do Socorro da Silva Azevedo, Moritz U. G. Kraemer, Renato Souza, Mariana Sequetin Cunha, Sarah C. Hill, Julien Thézé,
Michael B. Bonsall, Thomas A. Bowden, Ilona Rissanen, Iray Maria Rocco, Juliana Silva Nogueira, Adriana Yurika Maeda, Fernanda Giseli da Silva Vasami, Fernando Luiz de Lima Macedo, Akemi Suzuki, Sueli Guerreiro Rodrigues, Ana Cecilia Ribeiro
Cruz, Bruno Tardeli Nunes, Daniele Barbosa de Almeida Medeiros, Daniela Sueli Guerreiro Rodrigues, Alice Louize Nunes Queiroz, Eliana Vieira Pinto da Silva, Daniele
Freitas Henriques, Elisabeth Salbe Travassos da Rosa, Consuelo Silva de Oliveira, Livia Caricio Martins, Helena Baldez Vasconcelos, Livia Medeiros Neves Casseb,
Darlene de Brito Simith, Jane P. Messina, Leandro Abade, José Lourenço, Luiz Carlos Junior Alcantara, Maricélia Maia de Lima, Marta Giovanetti, Simon I. Hay, Rodrigo Santos de Oliveira, Poliana da Silva Lemos, Layanna Freitas de Oliveira, Clayton Pereira Silva de Lima, Sandro Patroca da Silva, Janaina Mota de Vasconcelos,
Luciano Franco, Jedson Ferreira Cardoso, João Lídio da Silva Gonçalves Vianez-Júnior, Daiana Mir, Gonzalo Bello, Edson Delatorre, Kamran Khan, Marisa Creatore,
Giovanini Evelim Coelho, Wanderson Kleber de Oliveira, Robert Tesh, Oliver G. Pybus, Marcio R. T. Nunes, and Pedro F. C. Vasconcelos
Published by AAAS 28
Fig.1TimeseriesandcartographyofreportedZIKVandmicrocephalycasesinBrazil
Nuno Rodrigues Faria et al. Science 2016;science.aaf5036
Published by AAAS 29
Fig.2MaximumlikelihoodphylogenyofZIKVcompletecodingregionsequences
Nuno Rodrigues Faria et al. Science 2016;science.aaf5036 Published by AAAS 30
Fig.3Timescaleoftheintroduc)onofZIKVtotheAmericas
Nuno Rodrigues Faria et al. Science 2016;science.aaf5036 Published by AAAS 31
OthermodesofZIKVtransmission(otherthanmosquito,intrauterine)• Sexual
– 2healthcareworkersreturnedfromSenegalin2008(Foyetal.EID2011fromCDC)
• Sexualtxfromcase1tohiswife(case3)uponreturntoCO• Sexualintercourse1dayajerhisreturn;3dayslater,case1developedprosta88s,hematospermiaandhiswifedevelopedflu-likeillness;shehadnotravelhistoryorknownmosquitoexposure;semenwasnotinves8gatedforRNAbutbothtestedZIKVseroposi8ve
– ZIKVRNAisolatedfromsemenandurinepublishedinEID,Feb2015bygroupinTahi8(Mussoetal.)
• Fever,weaknessdays1-3;arthralgiadays5-7• Hematospermia2weekslater;ZIKARNAposfromsemen;repeated3dayslaterandconfirmedinsemen(10^7copies/mL)andurine(10^3copies/mL);bloodnega8ve;virusalsocultureposfromsemen
– ZIKVRNArecoveredfromsemenofapa8entreturningfromtheCookIslandsondays27and62ajersymptomonset(Atkinsonetal.,EID2016)
– Casesinves8gatedintheUS(6countriesnowrepor8ng)32
Detec)onofZIKVinUrine;Gouriantetal.,EID;Jan2015
Wedescribethekine8csofZikavirus(ZIKV)detec8oninserumandurinesamplesof6pa8ents.Urinesampleswereposi8veforZIKV>10daysajeronsetofdisease,whichwasanotablylongerperiodthanforserumsamples
Triangles=urine;squares=serumDashedlineindicates>2dayintervalbetweensampling 33
ViralRamp-upStudyin3MacaquesinfectedwithZIKV
hbps://zika.labkey.com/project/OConner/begin.view
10^6copies/mL
10^4copies/mL
10^4copies/mL
34
Rossietal.,2016
MicelackingIFNreceptorsupportdiseaseandmortalitywhenZIKVchallengedAgedependentresponse(3wo=>deathvs11week=>diseasebutrecovered)Growthinthebrainbyday3withneurologicdiseasebyday6Robustreplica8oninthetestes
35
OthermodesofZIKVtransmission• Transfusion-highviral8tersupto14days
– 2casesfromBrazil(bothCampinas,SaoPauloState)– FirstMarch2015reportedtoHV
• 3dayspost-dona8on,reportDENV-likesymptomsfromdonor,laterdiagnosedasZIKV=>ZIKVRNApos(negDENV/CHIKV)
• Platelets=>liverrecipient,remainedasymptoma8cforZIKV,butRNApos(andculturepos;pre-txsampleneg)
• Sequenceiden8tybetweendonor/recipient– 2ndcaseApril2015
• Gunshotvic8mrec’d18components=>died• Recipientunexplainedthrombocytopeniapriortodeath;ZIKVculturepos(negDENV/CHIKV)
• Reten8onsamplesfrom18componentswerepartofarepositorystudy=>iden8fiedoneZIKVRNAposcomponentreceivedbyrecipient
• 3dayspost-dona8on,donorreportedsymptoms:rash,conjunc8vi8s,severeitching,generalizedpain,hypotension 36
UpdatedZIKVInfo(4/10/16)• CDCPublicHealthalerts–41areasincluding33intheAmericas,7
islandsintheS.Pacific,and1Africa(CapeVerde)– Usualmosquitoavoidancemeasures,DEET,longsleeves,pants,sleepunderabednet,removestandingwater
– Pregnantwomenavoidtravel;condoms,avoidcontactwithsemen
• Feb1WHOdeclarespublichealthemergencyofinterna8onalconcerntotriggeracoordinatedglobaleffortforeduca8on,surveillance,diagnos8cs,treatment,preven8on(mosquitocontrolandvaccinedevelopment),researchintocongenitalmalforma8onsandneurologicalcomplica8ons– Only4thinrecentyears:EBOV,Polio,H1N1flu– Est’d3-4millioncasesintheAmericasinthenext12monthsmodeledajerDENVintheAmericasin2015with~2millioncases(A.aegyp.inthe“dengue-belt”)
37
AllCountriesandTerritorieswithAc)veZikaVirusTransmission(4/10/16)
38
Considera)onsforBloodSafety
• Surveillance• Stopcollec8onsandrelyonimports• Enhanceddonorsymptomscreening• Enhancedcallback(PDI)=>Quaran8ne• 14-or28-daytraveldeferralsusedinnonendemicareas
• Rou8neblooddona8ontes8ng(NAT)• Pathogeninac8va8on
39
Detec)ngZIKVRNAandan)bodies
40
Inac)va)onofEmergingPathogens
Pathogen Inac)va)onInPC(Log10)WestNilevirus >6.0
Chikungunyavirus >6.4H1N1virus >4.1H5N1virus >5.9
Dengueviruses >5.0SARS-HCoV >6.3
ParvovirusB19 4=>5.5Orien*atsutsugamushi >5.5Trypanosomacruzi >5.3Babesiamicro* >5.3
Leishmaniamexicana >5.041
42
Valida)onofInterceptinac)va)onforZIKVinplasmaunits
Aubryetal.Transfusion2016
FDAGuidance2/16/16• Areaswithac)veZIKVtransmission;2-weekimplementa8on(March1)orimmediateforpregnantwomen,intrauterinetransfusionorotherriskgroupsasdefinedbythephysician;excep8onsrequirephysicianapprovalifdeemedurgent– ObtainwholebloodandcomponentsfortxfromareasoftheUSwherenoac8vetxisoccurring
– CanprepareplateletsandplasmausinganFDA-approvedPImethod(ormethodapprovedunderIDE)
– CantestusingalicensedNAT(ormethodapprovedunderIND)
– DHQmodifiedtoaskaboutadxors/s(cdc.gov)ofZIKVinfec8oninthepast4weeks;historyofsexualcontactinthepast4weekswithamanwhohasbeendxwithorhads/ssugges8veofZIKVinthe3monthspriortothelastsexualcontact 43
FDAGuidance2/16/16• Areaswithoutac)veZIKAtransmission;4-weekimplementa8on(March15)– Donoreduca8onalmaterialsallowingdonorstoselfdeferfor4weeks
• Riskfactorsands/sofZIKVinfec8onwithinthelast2weeksofleavinganac8veZIKVarea(cdc.gov)
• HistoryofZIKVinfec8onun8l4weeksajerresolu8onofsymptoms• SexwithamanwhohasbeendxwithZIKVorwhotraveledtoorresidedinanac8veZIKVareainthe3monthspriortothelastsexualcontact
• Travelnotspecificallymen8oned,butshouldbeincluded(riskfactors)– DHQmodifiedtoaskaboutresidenceortravelw/inlast4weeks(cdc.gov)
– PDIasabovewithdonordeferralfor4weeks– Productquaran8ne/retrievalofindatecomponentsforthosecollectedfromadonoratriskordxduringthe4-weekdeferralperiodorreportedasPDIwithinsubsequent2weeksofcollec8on;consigneeno8fica8onfromadonorwithaZIKVdxwithintheprior4weeksofdona8onor2weeksfollowingdona8on
44
ZIKVSigns/Symptoms(2ormore)fromcdc.gov
• Fever• Rash• Jointpain• Musclepain• Conjunc8vi8s(redeyes)• Headache
45
46
Es)mateddonordeferralrate(%)intheUSfroma14-or28-daydeferralbygeographicregion
comparing2surveysAreaoftravelinthepast:
SummerSurvey(Aug-Sept2014)Fixedsitesonly;papersurvey;
AmericasonlyprimarilyN=33,408
WinterSurvey(March2015)Allsites;electronicsurvey;
WorldwideN=19,879
14-day% 28-day% 14-day% 28-day%Mexico 0.19 0.52 0.40 0.92
Caribbean 0.16 0.48 0.48 1.18Centraland
SouthAmerica0.05 0.13 0.20 0.46
Allabove* 0.39 1.17 0.97 2.25Alltravel(global)*
N/A 2.64 1.35 3.96
47
*Individualareasandsumsarenotthesameduetoincompleterepor)ngoftraveldes)na)onandtraveltomul)pleplaces.Spenceretal.,AABB2015;Plenary
48
AdaptedfromBogochetal.,TheLancetJan142016
ZIKVdiseasecasesreportedtoCDCbyUSstateorterritory—2015–2016
(4/10/16)
LocalTravelContUS0346Territories3513
49
SequencingPRNT
EmergencyUseAuthoriza)on:TrioplexReal-)meRT-PCRforDENV,CHIKVandZIKVmul)plexrRT-PCRandZIKVMAC-ELISA(bothCDCassays) 50
*Mapsupdatedfromavarietyofsources;theyrepresentCDC'sbestes8mateofthepoten8alrangeofAedesaegyp.andAedesalbopictusintheUS.Mapsarenotmeanttorepresentriskforspreadofdisease.
ESTIMATEDrangeofAedesaegyp*andAedesalbopictusintheUS,2016Maps
51
Thismapes)mateswhichUSci)esfacethehighestriskfromZIKV
hbp://www.sciencealert.com/this-map-es8mates-which-us-ci8es-face-the-highest-risk-from-zika-virus 52
ZikaisComing;NYTimesApril92016;PeterHotezPredictedLoca)onsofAedesaegyp*intheSouthernUS
Factorsfavoringtransmission/spreadofZIKV:Aedesaegyp*,overcrowding,extremepoverty.“Incrowdedplaces,mosquitoeshavelotsofaccesstolotsofpeople.Poorpeopleojenliveinproximitytogarbage,includingold8res,plas8ccontainersanddrainageditchesfilledwithstagnantwater,wherethisspeciesofmosquitolivesandbreeds.Andtheyojenhavehomeswithtornscreensontheirwindows.” 53
Poten)alforlocaltransmissionislikelylow(astakenfromCDPH)
AviremicpersonwouldneedtoreturntoaregionwherethereareAedesmosquitoesandbebibenbyanAedesmosquitothatliveslongenoughtobecomeinfec8ousandbiteanotherperson
Aedestakes10-11daystobecomeinfec8ousajerbecominginfectedandthattheaveragelifespanisonly14daysThus,manyinfectedmosquitoeswilldiebeforebeingabletotransmitMi8ga8ngfactors:PatchyAedesaegyp.andalbopictusdistribu8onUseofaircondi8oners,windowanddoorscreensBeberwatermanagementthaninothercountriesGoodmosquitocontrol!
Ifanoutbreakweretooccur,itwouldlikelybelimitedinscopeanddura8onThefewlocaloutbreaksofDENVandCHIKVintheUShavebeencontainedTherefore,theUSwillprobablynotexperiencethesameextensiveoutbreakscurrentlybeingexperiencedinLa8nAmerica
54
DENV CHIKV
Year Local Imported Local Imported
2014 7(FL) 654 12(FL) 2799
2015 1(FL) 540 0 679
ComparisonofUS-reportedcasesofDENVandCHIKVtotheCDC,2014-2015
55
ZIKVcasesduetobloodtransfusionhavebeenreported–noneinUSyet!
(astakenfromCDPH)
Upondetec8onoflocalZIKVtransmissioninanystatelocalpublichealthagencieswouldinves8gateandenhancesurveillanceandmosquitocontrolintheareaBloodbankswouldbeinformedoflocaltransmissionsothatdonorsfromthearea(tobedefined)wouldbedeferredfromdona8ngbloodun8lbloodscreeningisinplace
56
KeyMessages(astakenfromCDPH)
Riskoflocaltransmissionofchikungunya,dengue,andZikavirusesintheUSislikelylowHowever,transmissionispossibleandwemustbepreparedtoaggressivelyrespondonceacasewithouttravelhistoryhasbeenreported
OngoingsurveillanceandcontrolofAedesarecri8calIndividualswithZika,dengue,orchikungunyashouldbeinformedtotakeprecau8onstoavoidmosquitobitesduringillnesstoavoidini8a8nglocaltransmissionShouldtherebelocaltransmission,theareaofexposureriskwouldbedeterminedbasedonhumanandmosquitosurveillancedataandgeographicboundaries,suchaszipcode,city,orcountywouldbedefinedandreported 57
• Providestateandlocalseniorofficialswithinforma8onandtoolsneededtoimproveZikapreparednessandresponsewithintheirstatesandjurisdic8ons.• IncreaseknowledgeonthelatestZikascience,includingimplica8onsforpregnantwomen.• Increaseknowledgeofbestcommunica8onsprac8ces,includingcrisisandriskcommunica8onprinciples.• AcceleratereadinessforlocalZikatransmissionthroughtrainingandtechnicalassistancetostatestohelpestablishandsupportsurveillanceandsharebestprac8cesforvectorcontrol.• Iden8fypossiblegapsinpreparednessandresponseatthefederal,state,andlocallevels;begintoaddresspossiblegaps. April1,2016 58
Defini)onofareasofac)vevector-bornetransmissionthatwouldac)vatebloodsafetyinterven)on(includingFDAguidance)–DRAFTCONCEPT
Twoormorelaboratory-confirmedinfec8onsduetolocalvector-bornetransmission(e.g.,notravelhistory,nocommonsexualexposure),andepidemiologicallyunrelatedtoeachother(e.g.,notsamehousehold)occurringwithintwoweeksinanaffectedarea Theaffectedjurisdic8onwilldetermine,onthebasisofsurveillance,popula8ondensityandvectorecology,anareaoflikelylocaltransmissionanddefinesuchareaonthebasisofaclusterofZIPcodes.ThisclusterofZIPcodeswillbedefinedastheareaofinterven8onTheclusterofZIPcodeswillbereportedbytheStatetotheCDC 59
Issues• Bloodsafety
– Screeningshouldbeinplacepriortoappearanceofvirus=>outbreaks–notthecurrentmodel
• Mosquitocontrol– Tradi8onalmethodsineffec8veagainstAedes– Biologic/gene8cvectorcontrol
• Infectedorengineeredmosquitoestoyieldsterileoffspring
• Vaccine– Timefordevelopment– An8body-dependentenhancement(ADE);wouldpriorflavivirusvaccina8on(YFV)orpriorprimaryinfec8on,orZIKVvaccineexacerbatediseaseinasecondaryinfec8on?
• Vaccine-inducedGuillain-Barrésyndrome 60
ZIKVcontrolrequiresanurgentandcoordinatedresponse
61