Zika and Dengue:Creating Partnerships to Interrupt Transmission.

ESRAGHOF #2921

June 12, 2017

Zika and Dengue: Creating Partnerships to Interrupt Transmission.

Zika, a virus borne by mosquitoes and globetrotting

humans, threatens the fetuses of pregnant women with

microcephaly and other devastating defects. A warming

world enables the viruses that cause Zika, Dengue and

other infectious tropical diseases, to flourish as the range

of their mosquito carriers expands. Though there are no

vaccines for Zika or Dengue, Clubs can implement service

projects that educate about Zika, clean up mosquito

habitat, promote personal prevention and implement an

exciting new method to interrupt mosquitos’ ability to

transmit these viruses.

Zika Advisory Madison AirportWisconsin, USA

Zika, Dengue and Chikungunya Travel

Advisories 2017

Margaret (Peggy) Honein, PhD, MPH Co-Lead, Pregnancy and Birth Defects Task Force, Zika Virus Response TeamChief, Birth Defects Branch, National Center on Birth Defects and Developmental Disabilities

Margaret (Peggy) Honein, PhD, MPH is an epidemiologist and co-lead of the Pregnancy and Birth Defects Task Force at the Centers for Disease Control and Prevention (CDC). Dr. Honein is also chief of the Birth Defects Branch at CDC, and was credentialed as a Distinguished Consultant/Senior Scientist in 2010. Dr. Honein received her BS degree in Biology from the University of California, Riverside in 1986, her MPH from the University of California, Los Angeles (UCLA) in 1992, and her PhD in Epidemiology from UCLA in 1995. Dr. Honein’s research interests include evaluating the effect of infections during pregnancy, assessing the safety or risk of medication use and vaccine use during pregnancy, understanding the role of smoking in birth defects, and examining longer term outcomes and costs associated with congenital heart defects and other birth defects across the lifespan.

CDC’S Response to Zika

Zika Virus: Update on a New Teratogen

Margaret Honein, PhD, MPHCenters for Disease Control and Prevention

Rotary International ConventionAtlanta, GeorgiaJune 12, 2017

First time in history…

“Never before in history has there been a situation where a bite from a mosquito could result in a devastating malformation.”– Dr. Tom Frieden, former CDC DirectorFortune, April 13, 2016

“…the last time an infectious pathogen (rubella virus) caused an epidemic of congenital defects was more than 50 years ago…”– New England Journal of Medicine, April 13, 2016

Level 1 is highest level

Level 1 Activations• Hurricane Katrina 2005• H1N1 Pandemic Flu 2009• Ebola 2014• Zika 2016

CDC Emergency Response Levels

Zika: The Basics

• Single-stranded RNA virus

• Flavivirus, closely related to dengue virus

• Primarily transmitted by Aedes aegypti

Additional modes of transmission

» Intrauterine and perinatal transmission

(mother-to-fetus)

» Sexual transmission

» Laboratory exposure

» Blood transfusion

Aedes aegypti mosquito

Aedes albopictus mosquito

What is Zika Virus?

• Clinical illness usually mild or asymptomatic

• Most common symptoms» Fever

» Rash

» Joint pain

» Conjunctivitis

» Headache

» Muscle pain

• Symptoms last several days to a week

• Severe disease uncommon

• Fatalities rare

• Once a person has been infected, likely to be protected from future infections

Clinical Presentation

• No vaccine or specific antiviral treatment

• Treat the symptoms» Rest

» Drink fluids to prevent dehydration

» Take medicine such as acetaminophen to reduce fever and pain

» Avoid aspirin and other non-steroidal anti-inflammatory drugs (NSAIDS) until dengue can be ruled out to reduce the risk of bleeding

• Serious implications for Zika virus infection during pregnancy

Clinical Management

Areas with Risk of Zika

As of May 26, 2017

https://wwwnc.cdc.gov/travel/page/world-map-areas-with-zika

Note: Zika risk is determined according to altitude (height above sea level). Mosquitoes that spread Zika usually do not live at high altitudes (above 6,500 feet or 2,000 meters). The risk of getting Zika from a mosquito at high altitudes is less than at low altitudes.

Zika, Pregnancy, and Congenital Zika Virus Infection

• Preventing Zika virus infection during pregnancy

• Clinical guidance and outreach to obstetric and pediatric providers

» Testing and clinical management

• Monitoring effect of Zika virus infection on pregnant women and infants

» Pregnancy registries

» Birth defects surveillance

• Research to better characterize timing of risk and potential co-factors

Protecting Pregnant Women and Infants from Zika

• Zika virus can pass from a pregnant woman to her fetus during pregnancy

• Zika during pregnancy can cause damage to the brain, microcephaly, and congenital Zika syndrome

• Linked to other problems such as miscarriage, stillbirth, and birth defects

• No evidence that past infection will affect future pregnancies once the virus has cleared the body

How can Zika affect pregnancies?

• Recognized pattern of congenital anomalies associated with Zika virus infection

during pregnancy that includes» Severe microcephaly (small head size) resulting

in a partially collapsed skull

» Decreased brain tissue with brain damage

» Damage to the back of the eye

» Limited range of joint motion

» High muscle tone restricting body movement

• Zika virus also linked to» Hearing loss

» Limb abnormalities

» Impaired growth

Moore CA, Staples JE, Dobyns WB, Pessoa A, Ventura CV, Fonseca EBD, Ribeiro EM, Ventura LO, Neto NN, Arena JF, Rasmussen SA. Characterizing the Pattern of Anomalies in Congenital Zika Syndrome for Pediatric Clinicians. JAMA Pediatr. Published online November 03, 2016. doi:10.1001/jamapediatrics.2016.3982

Congenital Zika Syndrome

Ocular Findings and Congenital Contractures

Moore CA, Staples JE, Dobyns WB, Pessoa A, Ventura CV, Fonseca EBD, Ribeiro EM, Ventura LO, Neto NN, Arena JF, Rasmussen SA. Characterizing the Pattern of Anomalies in Congenital Zika Syndrome for Pediatric Clinicians. JAMA Pediatr. Published online November 03, 2016. doi:10.1001/jamapediatrics.2016.3982

Congenital Zika Syndrome – Other Neurologic Sequelae

• Information on long-term medical and developmental outcomes or mortality sparse

• Neurologic sequelae reported to date in addition to contractures include the following

» Motor and cognitive disabilities

» Epilepsy

» Swallowing difficulties

» Vision loss and hearing impairment

» Hypertonia and spasticity with tremors

» Irritability with excessive crying

• Microcephaly from congenital infection can occur after birth

• The full spectrum of poor outcomes caused by Zika virus infection during pregnancy

remains unknown

Head circumference in normal range at birth

(0.8 SD below the mean)

Microcephaly at age 12 months (4.3 SD below the mean)

Congenital Zika Syndrome without Microcephaly at Birth

Potential Risk of Birth Defects Related to Zika

• 5% with possible Zika had birth defects

• 10% with confirmed Zika had birth defects

Nearly 1,000 US pregnant women with laboratory evidence of Zika completed their pregnancies in 2016*, and some had babies with Zika-related birth defects:

Reynolds MR, Jones AM, Petersen EE, et al. Vital Signs: Update on Zika Virus–Associated Birth Defects and Evaluation of All U.S.Infants with Congenital Zika Virus Exposure — U.S. Zika Pregnancy Registry, 2016. MMWR Morb Mortal Wkly Rep 2017;66:366-373.

*Data from US Zika Pregnancy Registry (50 states and DC)

Pregnant women with any laboratory evidence of possible Zika virus infection in the 50 US states and DC

Pregnant women with any laboratory evidence of possible Zika virus infection in US territories

3,916

Pregnant Women with Any Laboratory Evidence of Possible Zika Virus Infection in the United States and Territories

1,883

*Includes aggregated data reported to the US Zika Pregnancy Registry as of May 23, 2017**Includes aggregated data from the US territories reported to the US Zika Pregnancy Registry and data from Puerto Rico reported to the Zika Active Pregnancy Surveillance as of May 23, 2017

* *

• Number of completed pregnancies with or without birth defects: 1,579

• Of these

» 72 live born infants born with a birth defect consistent with congenital Zika infection

» 8 pregnancy losses affected by a birth defect consistent with congenital Zika infection

*Outcomes for Completed Pregnancies in the US States and District of Columbia, 2016-2017As of May 23, 2017

Pregnancy Outcomes among US Women* with Evidence of Zika

*Late breaking data; as of April 25, 2017

Zika-Related Pregnancy Outcomes in US Territories*

• 2,549 women in the US territories with laboratory evidence of recent possible Zika virus infection completed their pregnancy

» 122 (5%) had fetuses or infants with Zika-related birth defects

• Among pregnant women with positive nucleic acid test results confirming Zika virus infection

» 8% infected in the 1st trimester had a fetus or infant with birth defects

» 5% infected in the 2nd trimester had a fetus or infant with birth defects

» 4% infected in the 3rd trimester had a fetus or infant with birth defects

Zika Prevention and Testing

• Pregnant women should not travel to

areas with risk of Zika

• If a pregnant woman must travel, she should

» Talk with her healthcare provider before she goes

» Strictly follow steps to prevent mosquito bites during

the trip

» Take steps to prevent sexual transmission

» Talk with her healthcare provider after she returns,

even if she doesn’t feel sick

http://wwwnc.cdc.gov/travel/page/zika-information

Do Not Travel to Areas with Risk of Zika

• Wear long-sleeved shirts and long pants

• Stay and sleep in places with air conditioning or that

use window and door screens

• Use EPA-registered insect repellents with one of the

following active ingredients:

» DEET, picaridin, IR3535, oil of lemon eucalyptus, para-

menthane-diol, or 2-undecanone

• Once a week, empty and scrub, turn over, cover, or

throw out items that hold water, such as trash

containers, tires, buckets, toys, planters, flowerpots,

birdbaths or pools

If a pregnant woman lives in or travels to an area with Zika, she should

Prevent Mosquito Bites

A pregnant woman whose partner lives in or has traveled

to an area with risk of Zika should

Prevent Sexual Transmission of Zika Virus

• Use condoms correctly every time they have sex, or

• Not have sex

For the duration of the pregnancy, even if the pregnant

woman’s partner does not have symptoms or feel sick.

• A doctor or other healthcare provider may

order tests to look for Zika or similar types

of infections

• CDC developed tests that received FDA

Emergency Use Authorizations to diagnose

Zika virus infection

» rRT-PCR Trioplex

» MAC-ELISA

• Commercial lab assays are increasingly

available

How is Zika Diagnosed?

• Limited timeframe for detection of Zika

virus RNA or IgM antibodies

• Cross-reactivity of Zika virus antibodies

with antibodies of other similar viruses,

like dengue

• Limited data on viral persistence

Challenges for Zika Diagnostics

• All pregnant women (regardless of symptoms) who

» Live in or recently traveled to an area with risk of Zika that has a CDC

Zika travel notice, or

» Had unprotected sex with a partner who lives in or traveled to an area

with risk of Zika that has a CDC Zika travel notice

• Pregnant women who live in or recently traveled to an area with

risk of Zika but without a CDC Zika travel notice

» If they develop symptoms of Zika, or

» If their fetus has abnormalities on an ultrasound that may be related

to Zika virus infection

https://www.cdc.gov/zika/hc-providers/pregnant-women/testing-pregnant-women.html

Who Should Be Tested for Zika?

CDC recommends laboratory testing for

• All infants born to mothers with laboratory evidence

of Zika virus infection during pregnancy

• Infants who have abnormal clinical or neuroimaging

findings suggestive of congenital Zika syndrome and a

mother with a possible exposure to Zika virus,

regardless of maternal Zika virus testing results

Testing Babies for Zika

https://www.cdc.gov/zika/hc-providers/infants-children/evaluation-testing.html

What is CDC Doing?

• Purpose

» Monitor pregnancy and infant outcomes in pregnancies with Zika virus infection to inform clinical guidance and public health response

• Who is included

» Pregnant women with laboratory evidence of possible Zika virus infection

» Infants with laboratory evidence of congenital Zika virus infection

» In Colombia – based on maternal symptomatic Zika virus disease

US Zika Pregnancy Registry

Zika Active Pregnancy Surveillance System (Puerto Rico)

Proyecto Vigilancia deEmbarazadas con Zika (Colombia)

Collecting Data: Zika Pregnancy and Infant Registries

Sharing Up-to-Date Information

• Providing updated clinical guidance» Travel, testing, and other recommendations for pregnant women

» Published updates to clinical guidance and algorithms for healthcare providers caring for pregnant women and infants

• Responding to your inquiries» Email: ZikaMCH@cdc.gov

» Zika Pregnancy Hotline: 770-488-7100

• Providers and the general public can also ask questions through CDC-INFO

» Call 1-800-CDC-INFO (1-800-232-4636)

» Visit www.cdc.gov/cdc-info

https://www.cdc.gov/zika/hc-providers/index.html*Free materials available in English, Spanish, and other languages

Developing Tools for Healthcare Providers

For more resources to share with families, visit: http://www.cdc.gov/zika/fs-posters/index.htmlAvailable in English, Spanish and other languages

Resources for Families

• Referral Network

Identify specialty healthcare providers

» Maternal-fetal medicine, mental health services, audiology, radiology, pediatric ophthalmology, pediatric neurology, developmental pediatrics, infectious disease, and endocrinology

» Consider joining the network if you are a healthcare professional located within one of the Zika Care Connect focus areas

• Professional Resources

Information for healthcare professionals caring for patients with Zika

» Links to materials from American Academy of Pediatrics,

American College of Obstetricians and Gynecologists, CDC,

and March of Dimes

» Contact information for the CDC Zika Pregnancy Hotline

Website: www.zikacareconnect.org

HelpLine: 1-844-677-0447 (toll-free)

Zika Care Connect: Improving Access to Clinical Services

What Can You Do?

Educate families on Zika prevention

Connect with local health departments

Support babies and families

How You Can Help

Available online at https://www.cdc.gov/zika/comm-resources/toolkits.html

CDC Zika Educational Materials

CDC’S Response to Zika

More information on Zikawww.cdc.gov/zikahttps://www.cdc.gov/mmwr/zika_reports.html

For questions about CDC’s work related to Zika and unintended pregnancy, contact CDC-INFO at 1-800-232-4636 or www.cdc.gov/cdc-info

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.