BCDH Health Update: Zika Virus

February 10, 2016

February 9 Update

Please see the updated guidance for Zika virus diagnosis, management and reporting (replaces guidance of 1/28/16).  (click here for updated document)
 
Remember that physicians and laboratories are required to report suspected or confirmed Zika virus and that approval is required for submission of specimens. 
  • Please contact the Communicable Disease Branch at 919-733-3419 or your local health department (828-250-5109 for Buncombe County Disease Control) to facilitate testing if Zika virus infection is suspected.
  • Specimen transport using the statewide courier can be coordinated with your local health department or specimens can be directly shipped to the NC State Lab of Public Health using a professional courier service.  All specimens should be packaged and shipped as a Category B infectious substance.
New info in memo includes:

Epidemiology

  • To date, most cases identified in the continental US have been among persons with recent travel to an area of ongoing transmission; one locally-acquired case in Texas was linked to sexual transmission.
  • Isolated cases of Zika virus transmission through blood transfusion and sexual contact have been reported elsewhere.
  • Zika virus, like dengue, can be detected in saliva and urine. However, exposure to these fluids has not been linked to transmission. 

Zika Virus Infection and Pregnancy

  • Serologic testing for Zika virus can also be offered to asymptomatic pregnant women 2–12 weeks after travel to areas with ongoing transmission.
  • Biparietal diameter and head circumference are used to detect microcephaly on ultrasound. Normally, these measurements are not used before 14 weeks gestation. There is limited information regarding timing or diagnostic accuracy of ultrasound for detection of fetal microcephaly or intracranial calcifications associated with Zika virus infection. 

Prevention Measures

Mosquito avoidance: The mosquitoes responsible for most Zika virus transmission are not believed to be widespread in North Carolina. However, persons being evaluated for Zika virus infection should still be advised to use personal protective measures to avoid exposure to mosquitoes during the first 7 days after symptom onset. These measures include:
  • Avoiding outdoor exposure when mosquitoes are most active. The mosquitos that transmit Zika virus are aggressive daytime biters, so always use personal preventive measures to prevent bites at all times of day.
  • Using personal preventive measures – i.e., wearing insect repellent and covering up: http://www.cdc.gov/features/stopmosquitoes/
  • Reducing breeding sites for Aedes species mosquitoes in your yard: http://epi.publichealth.nc.gov/cd/arbo/mosquito_fs.pdf  
Additional measures:
  • Refrain from donating or selling any blood products until symptoms have resolved and until 28 days after travel to an area with ongoing transmission.
  • Men who reside in or have traveled to an area of active Zika virus transmission who have a pregnant partner should abstain from sexual activity or consistently and correctly use condoms during sex (i.e., vaginal intercourse, anal intercourse, or fellatio) for the duration of the pregnancy.
  • Men who reside in or have traveled to an area of active Zika virus transmission and have non-pregnant sex partners might consider abstaining from sexual activity or using condoms consistently and correctly during sex until more is known about persistence of virus in semen and factors associated with sexual transmission.
This is an evolving situation and recommendations are likely to change as new information becomes available. Updated information and guidance are available from CDC at http://www.cdc.gov/zika.  
 
As always, contact Buncombe County Disease Control at 828-250-5109 if you have any questions regarding this or other communicable disease matters.
 
Thanks,
Jennifer Mullendore, MD, MSPH
Medical Director
Buncombe County Health and Human Services
Office:  (828) 250-6308
 

January 28 Update

 
The NC Division of Public Health just today sent out guidance (below) pertaining to Zika virus diagnosis, management and reporting. This guidance is similar to my post a couple days ago, but contains more specifics about testing. Keep in mind that if you suspect someone of having Zika virus you need to notify your local health department or the NC Communicable Disease Branch.
 
NC DPH is developing web content related to Zika virus which will be available at http://epi.publichealth.nc.gov/cd/.
 
To contact Buncombe County Disease Control staff, call 828-250-5109 (available 24/7).
 
Thanks,
Jennifer Mullendore, MD, MSPH
Medical Director
Buncombe County Health and Human Services
Office:  (828) 250-6308
 

 

To:         North Carolina Health Care Providers and Laboratories

From:     Megan Davies, MD, State Epidemiologist

              Scott Zimmerman, DrPH, MPH, HCLD (ABB), State Laboratory of Public Health

              Belinda Pettiford, MPH, Women’s Health Branch

 

Subject:  Zika Virus Diagnosis, Management and Reporting (3 pages)

 

This memo is intended to provide information to NC clinicians and laboratories regarding diagnosis, management and reporting of Zika virus infection.

 

Summary:

Zika is a mosquito-borne virus that is currently causing a large outbreak in Brazil, including reports of pregnant women giving birth to babies with birth defects. Zika virus was first identified in Uganda in 1947 and is transmitted by Aedes aegypti and A. albopictus mosquitos. Since 2007, Zika virus has caused large outbreaks in Gabon, Micronesia and French Polynesia. Since 2015, endemic transmission has been occurring in Central and South America. A map of affected areas is available at http://www.cdc.gov/zika/geo/index.html. To date, only travel-associated cases have been identified in the United States. No cases have been reported in North Carolina.

 

Clinical and Epidemiologic Features:

Approximately 1 in 5 people infected with Zika virus become ill. Symptoms begin about 3–12 days after exposure, last between 2 and 7 days and include mild fever, rash (mostly maculopapular), headaches, arthralgia, myalgia, and non-purulent conjunctivitis. Patients may remain viremic for up to 7 days after symptom onset. Clinical symptoms are often similar to dengue and chikungunya infections.

 

Case management

Because of similar geographic distribution and symptoms, patients with suspected Zika virus infections also should be evaluated and managed for possible dengue or chikungunya infection. Similar to dengue and chikungunya infections, no specific antiviral treatment is available for Zika virus infection. Treatment is generally symptomatic and can include rest, fluids, and use of acetaminophen. Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs), like ibuprofen and naproxen, should be avoided until dengue can be ruled out to reduce the risk of hemorrhage.

 

Zika Virus Infection and Pregnancy:

Due to reports of microcephaly and other poor outcomes in babies of mothers who were infected with Zika virus while pregnant, the CDC recommends that pregnant women consider postponing travel to areas where Zika virus transmission is ongoing. Pregnant women and women trying to become pregnant who do travel to these areas should talk to their healthcare providers first and strictly follow steps to avoid mosquito bites during their trip.

 

Health care providers should ask all pregnant women about recent travel. Pregnant women who develop symptoms consistent with Zika virus infection within two weeks of travel to an area with ongoing transmission should be evaluated by a health care provider and recommended for testing as described below.

 

CDC and the American Congress of Obstetricians and Gynecologists (ACOG) recommend that an ultrasound evaluation be performed for asymptomatic pregnant women reporting travel at any time during pregnancy to an area with ongoing transmission in order to detect fetal microcephaly or intracranial calcifications. Serial ultrasound screening (every 3-4 weeks) may be considered at the discretion of the provider. Additional recommendations for management of pregnant women with travel history to an area with ongoing Zika virus transmission are available at http://www.cdc.gov/zika/pdfs/questions-answers-clinicians.pdf and https://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Interim-Guidance-for-Care-of-Obstetric-Patients-During-a-Zika-Virus-Outbreak.

 

Recommendations for additional assessment and laboratory testing for infants with possible congenital Zika virus infection are available at http://www.cdc.gov/zika/hc-providers/qa-pediatrician.html.

 

Laboratory Testing:

Testing for Zika virus should be conducted in consultation with the state and local public health for the following individuals:

 

            Pregnant women

·         Pregnant women presenting with signs and symptoms consistent with Zika virus disease (acute onset of fever, maculopapular rash, arthralgia, or conjunctivitis) within two weeks of travel to an area with ongoing transmission, or

·         Asymptomatic pregnant women who have ultrasound findings of fetal microcephaly or intracranial calcifications and who report travel to an area with ongoing transmission during pregnancy.

 

Non-pregnant persons

·         Patients presenting with signs and symptoms consistent with Zika virus disease (acute onset of fever, maculopapular rash, arthralgia, or conjunctivitis) within two weeks of travel to an area with ongoing transmission.

 

Approval is required for submission of specimens. Please contact the Communicable Disease Branch at 919-733-3419 or your local health department to facilitate testing if Zika virus infection is suspected.

 

Testing methods

Because of concurrent circulation of Zika, dengue, and chikungunya viruses and the similarity of illness presentation, CDC recommends concurrent testing for all three viruses in patients with a recent history of travel to an affected area and clinically compatible illness.

 

Appropriate testing is determined based on how long after symptom onset the specimen is collected.

 

·         Specimens collected <4 days after symptom onset will be subjected to molecular testing (RT-PCR) for all three viruses.

·         Specimens collected 4–7 days after symptom onset will be subjected to molecular testing and serologic testing for virus-specific IgM antibodies. Because serum collected within 7 days of illness onset may not have detectable virus-specific IgM antibodies, IgM testing should be repeated on a convalescent-phase sample.

·         Specimens collected >7 days after symptom onset will be subjected to serologic testing for virus-specific IgM antibodies.

 

Where to test

Testing for Zika, dengue, and chikungunya viruses will be coordinated by the NC State Laboratory of Public Health (NCSLPH) and conducted in collaboration with CDC. The provider for each patient should complete the following forms:

 

·         The NCSLPH submission form DHHS 3445, which is available at http://slph.state.nc.us/virology-serology/special-serology.asp.  (At the bottom of this form, please check “Forward to CDC” and write in specific tests requested. NCSLPH will perform chikungunya molecular and serological testing with a 6 business day turn-around-time.)

·         The CDC 50.34 DASH form, which is available at http://slph.ncpublichealth.com/Forms/CDC-5034-DashForm-120515.pdf. This form must be completed online and then printed. Be sure to use ‘Test Order Name’ as ‘Arbovirus Serology.’

 

Because of the extensive cross-reactivity between the Flaviviruses, the following information must be provided with submitted specimens:

·         Travel history, onset date, specimen collection date, specimen type, description of clinical illness, vaccination history (specifically yellow fever and Japanese encephalitis vaccines), and submitter contact information.

·         When submitting perinatal specimens or specimens collected from pregnant women, please include the gestational age of the fetus at the time of travel.

Submitters should also request testing for all three viruses on both test request forms. Both forms should be completed for all specimens, acute and convalescent, and should be submitted to the NC SLPH.

 

Table: specific specimen collection, testing, and shipment information for Zika, Chikungunya and Dengue Testing:

Specimen

Test Performed

Specimen Volume

Shipment

 

Serum

 

Chikungunya RT-PCR & IgM;
Zika and Dengue RT-PCR and virus-specific IgM;

Flavivirus PRNT

 

 

2–5 mL serum

 

 

Refrigerated (4°C), placed on cold packs if shipment is to be received within 72 hrs of collection. For delays exceeding 72 hrs, freeze at -70°C & ship on dry ice.

 

Amniotic Fluid*

 

Zika RT-PCR

 

0.5–3 ml

 

Refrigerated (4°C), placed on cold packs if shipment is to be received within 72 hrs of collection. For delays exceeding 72 hrs, freeze at -70°C & ship on dry ice.

 

 

Cord Blood

 

Zika RT-PCR & IgM; Flavivirus PRNT

 

 

0.5–3 ml

 

Refrigerated (4°C), placed on cold packs

 

Placental Tissue

 

 

Zika RT-PCR;

Viral Culture

 

 

2–5 grams

 

Freeze at -70°C & ship on dry ice.

 

Placental Tissue and Umbilical Cord

 

Immunohistochemical Staining & Zika virus RT-PCR

 

2–5 grams of tissue and/or paraffin blocks

 

Tissue should be formalin-fixed or paraffin-embedded. Ship specimens at room temperature.
Note: Request consultation with NCSLPH for specific instructions.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

*Patient and healthcare provider must weigh risks and benefits of testing prior to collection of amniotic fluid.

 

Contact the NCSLPH at 919-807-8600 prior to any shipment or if you have questions. All specimens should be shipped as a Category B Biological Substance.

 

Address all specimen shipments as follows:       Attention: Virology/Serology Unit

                                                                       North Carolina State Laboratory of Public Health

4312 District Drive

Raleigh, NC 27607-5490

 

Surveillance and Reporting:

Please contact the Communicable Disease Branch at 919-733-3419 or your local health department if Zika virus infection is suspected. As a reminder, dengue and chikungunya infections are specifically reportable per 10A NCAC 41A .0101.

 

This is an evolving situation and recommendations are likely to change as new information becomes available. Updated information and guidance are available from CDC at http://www.cdc.gov/zika.  

 
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