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The Delaware Division of Public Health (DPH) is issuing this health advisory to advise health care providers of the need to carefully monitor children may have been exposed to the Zika virus during pregnancy.
Zika virus is transmitted to humans primarily through the bite of an infected Aedes species mosquito (Ae. aegypti and Ae. albopictus). These are the same mosquitoes that spread dengue and chikungunya viruses. These mosquitoes are aggressive daytime biters, but they can also bite at night. They typically lay eggs in and near standing water. They become infected when they feed on a person already infected with the virus. Infected mosquitoes can then spread the virus to other people through bites. Both Aedes species that spread the Zika virus are found in Delaware and in many south and eastern shore states. However, there has been no evidence of local transmission of Zika virus in Delaware or our neighboring states as of July 27.
Zika virus is a flavivirus transmitted primarily by the bite of infected Aedes mosquitoes. In addition, sexual, in utero, and perinatal transmission have been documented.
Globally, Zika virus transmission by mosquitoes has been reported in 50 countries and territories. In the continental U.S., as of August 1st , 2016, the vast majority of cases of mosquito-borne Zika infection have been travel related. However, the state of Florida has confirmed local mosquito transmission in 14 cases of Zika virus infection that occurred in non-travelers within a one-mile radius north of Miami. In Delaware, of 144 individuals tested for Zika virus as of August 1st , 2016, 10 are laboratory confirmed cases and all were travel related.
All primary care providers caring for children in Delaware should be diligent to:
While mosquito-borne transmission is the primary mode of Zika transmission, another mode of transmission of the virus is through sexual contact. The virus has been isolated in both semen and female genitalia secretions; its presence in semen exceeds the time of viremia. Sexual transmission from male to female and from female to male have both been documented.
The most worrisome mode of transmission of the Zika virus is the transmission from mother to fetus during pregnancy. Zika virus infection during pregnancy has been linked with fetal and infant microcephaly, other fetal brain abnormalities, and poor pregnancy outcomes.
Perinatal transmission of Zika virus occurs when a woman is infected with the Zika virus within the two weeks prior delivery, and the virus passes to the infant at or around the time of delivery.
Zika virus has been identified in breast milk, but there is no evidence of transmission of Zika virus to the infant via breastfeeding. With the benefits of breastfeeding outweighing the theoretical risk of Zika virus transmission, current recommendations encourage mothers with Zika virus infection and mothers living or traveling in areas with ongoing Zika virus transmission to breastfeed their infants.
Most people infected with Zika virus are asymptomatic. For the estimated 20 percent who are symptomatic, the illness is usually mild with duration of symptoms spanning from several days to a week. Characteristic clinical findings include acute onset of fever with pruritic maculopapular rash, arthralgia, or conjunctival hyperemia (no discharge). Myalgia, edema of hands and feet, and headache have also been reported. Severe disease requiring hospitalization is uncommon and case fatality is low. However, Guillain-Barre syndrome has been reported in patients following suspected Zika virus infection.
Zika virus infection during pregnancy can cause intrauterine growth retardation, microcephaly and other severe brain defects in the fetus. Imaging studies have demonstrated intracranial calcifications in the periventricular, parenchymal, and thalamic regions, similar to that found with other congenital infections. Abnormal formation or absence of brain structures, and neuronal migration disorders may also occur. Vision-threatening ocular findings also have been reported, including microphthalmia, lens subluxation, cataracts, chorioretinal atrophy, macular chorioretinitis, optic nerve abnormalities, and intraocular calcifications. Reported neurologic findings include hypertonia, hyperreflexia, irritability, tremors, seizures, brainstem dysfunction, and dysphagia. Other findings include excessive and redundant scalp skin, arthrogryposis, and clubfoot.
Few cases of infants with perinatally acquired Zika infection have been described with mild disease with the most significant manifestation being transient thrombocytopenia.
Zika virus diagnostic testing is recommended for pregnant women who have traveled to areas with active Zika virus transmission or who had unprotected sex with a Zika-infected partner regardless of the presence or absence of symptoms in the pregnant woman. Infants with microcephaly or intracranial calcifications born to women who traveled to or resided in an area with Zika virus transmission while pregnant, and infants born to mothers with positive or inconclusive Zika virus test results should also be tested for Zika. In addition, testing is recommended for individuals with symptoms consistent with Zika who have traveled to an area with ongoing Zika transmission.
Serum and urine PCR for Zika virus are available through the Delaware Public Health Laboratory as well as through several commercial laboratories. Serology testing (Zika IgM antibody capture Enzyme-linked immunosorbent assay: Zika MAC-ELISA) is offered through the Delaware Public Health Laboratory and recently has become available in a few commercial laboratories
PCR testing is indicated for serum samples collected fewer than seven days and urine samples collected fewer than 14 days after symptom onset. While a positive PCR test is confirmatory of Zika virus infection, a negative PCR test result does not exclude Zika virus infection and serologic testing by ELISA for Zika IgM antibody should be completed. If a health care provider receives a negative PCR result in a person with relevant travel, they should contact DPH to arrange for serology testing which is reliable in detecting Zika infection two to 12 weeks after symptom onset.
Treatment is supportive but NSAIDS and aspirin should be avoided until infection with dengue (which has overlapping symptomatology and geographic distribution) has been excluded. This is to avoid hemorrhagic complications which might ensue if a patient with dengue is inadvertently treated with these medications.
While there are a number of candidate vaccines as well as antiviral medications that are being investigated, currently, they are all in experimental phases and none is recommended for treatment or prevention of infection for humans.
While there is no evidence of local transmission of Zika virus via mosquitoes in Delaware, the Aedes mosquitoes that transmit the virus are found in our state and the neighboring states. Thus, it is prudent to take measures to avoid mosquito bites. For a comprehensive list of measures and an updated list of prevention efforts, visit http://dhss.delaware.gov/dhss/dph/zika.html.
Pregnant women should also be counseled to avoid unprotected sex with male or female partners who have returned from travel to areas where there is ongoing transmission of Zika virus. Pregnant women should either not have sex with returned travelers for the duration of pregnancy, or use effective barrier methods such as condoms or dental dams for all sexual contact for the duration of the pregnancy.
U.S. Zika Pregnancy Registry (http://www.cdc.gov/zika/pdfs/pregregistry-pediatricians-fs.pdf). In collaboration with state, tribal, local, and territorial health departments, information is collected about pregnancy and infant outcomes following laboratory evidence of Zika virus infection during pregnancy.
All health care providers caring for infants in Delaware are asked to contribute to the registry by reporting suspected congenital Zika cases to DPH. As a nationally notifiable disease, Zika virus infection should be reported to DPH Office of Infectious Disease Epidemiology by phone at 302-744-4990 or by filling out one of the forms (available at http://dhss.delaware.gov/dhss/dph/files/zikaneonate.pdf and http://dhss.delaware.gov/dhss/dph/files/zikainfant.pdf ) and fax or email to the Office of Infectious Disease Epidemiology at 302-223-1540 or reportdisease@delaware.gov.
While many infants will be identified prenatally, the role of pediatric health care providers is of great importance since they may identify previously unrecognized cases of congenital Zika infection as well as infants perinatally exposed.
Health care providers should report clinical information for infants of women with confirmed or suspected Zika infection at birth and at 2, 6, and 12 months of age. For the initial evaluation and the long-term follow up of these infants, the CDC provides guidance on what is pertinent information at http://www.cdc.gov/zika/pdfs/pediatric-evaluation-follow-up-tool.pdf.
More specifically, for all infants whose mothers had positive or inconclusive Zika virus tests, a thorough physical examination is paramount, to include careful measurement of head circumference, length, weight, and assessment of gestational age. A complete neurologic evaluation should be performed as well as recording of dysmorphic features, hepatosplenomegaly, and rash or other skin lesions (photographs of any rash, skin lesions, or dysmorphic features are encouraged). Cranial ultrasounds and ophthalmologic and hearing assessments are all part of the initial evaluation.
For all infants born to mothers with positive or inconclusive Zika virus test, the long term follow up consists on visits at 2, 6, and 12 months of age with detailed recording of physical findings and evaluation of development. A repeat hearing screening is recommended at 6 months of age.
For those infants in which microcephaly or other findings consistent with congenital Zika virus infection have been found, additional evaluation items consist of consultation with pediatric subspecialists according to the examination findings as well as laboratory tests (e.g. complete blood count, liver function tests, and liver enzymes).
Health care providers who care for infants with suspected or confirmed Zika infection should consider recommending psychological counseling to families as well as special guidance on issues like child care, return to work, communication with other family members, and parenting of other children. For further information on Delaware resources to parent special needs children, call 302-744-4704.
Contact DPH Office of Infectious Disease Epidemiology at 888-295-5156 or 302-744-4990 for guidance with regard to specimen collection, coordination of testing, and further information and to report suspected cases of Zika virus infection or exposure of pregnant women or children.
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