Screening

 

History

Mild Fever; travel history for pregnant patients; had sexual contact with someone who has recently traveled to a Zika-affected area (http://www.cdc.gov/zika/geo/)

The mosquito-borne disease, which is also sexually transmitted, is of greatest concern to pregnant women and those trying to become pregnant and their partners because of the devastating consequences it can have on a fetus.
As of May 20, the most recent data available, the Puerto Rico Department of Health reported (PDF) 40,330 confirmed cases of the Zika virus since the outbreak began last year. Four hundred twenty-two of those infected have been hospitalized, and five individuals have died. Among those cases, there have been 52 Zika-related cases of Guillain-Barre Syndrome, a type of temporary paralysis that is caused by viruses including Zika. The Puerto Rico Department of Health has reported only 38 cases of Zika-related birth defects.

 

Laboratory Test


Patients must have a positive travel history AND development of symptoms consistent with Zika within two weeks of travel in order for testing to be performed.  For complete details, please review the updated Morbidity and Mortality Weekly Report (MMWR) (http://www.cdc.gov/mmwr/volumes/65/wr/mm6505e2er.htm?s_cid=mm6505e2er_w).  If you have already completed and faxed a case report form to the DC DOH for a pregnant, asymptomatic woman, you do not need to complete another one.  The CDC also released new recommendations on Zika virus and sexual transmission (http://www.cdc.gov/mmwr/volumes/65/wr/mm6505e1er.htm?s_cid=mm6505e1er_w).  Please reach out to all patients you have seen regarding Zika virus that these new recommendation may impact. The DC DOH will not communicate clinical recommendations directly to patients and it is the responsibility of health care providers to pass the information along.  Due to the small window of time that Zika virus is likely viremic, it is important to educate suspected Zika virus patients on mosquito-exposure reduction practices and decreasing the risk of sexual transmission the day they are seen. Final test results will not return until after control interventions are most effective and it is important to educate patients early to reduce the chance they will serve as a reservoir as we enter mosquito season. Updated procedures for providers submitting samples  Fill out the Communicable Disease Case Report Form for suspected cases and fax it to (202) 442- 8060. Please include your email on the case form. o For all pregnant women with a positive travel history, please draw and keep a serum sample until testing is arranged. o For all others, please contact the DC DOH at (202) 442 -8141 to ensure the patient qualifies for testing.  After the case form is faxed and received by the DC DOH, you will receive an email from us with a case number and further instructions to coordinate sample pick-up for shipment to CDC.  If you have not already, please send the email address to DOH.EPI@dc.gov of someone at your facility that will always be responsible for coordinating sample pickups. Please include the name of your facility and a phone number.  Please let the patient know to expect a call from us once you submit the report form with their contact information. o Do not instruct patients to call us on their own. o We will interview all patients, even those with a positive travel history but without symptoms of Zika.  When calling with Zika virus inquires please leave a direct number where you can be reached and not the general number for your facility. This will help expedite our response if we can call you back directly and bypass the general phone service for your facility. 3  Notification to DOH should occur the day the patient is seen to ensure timely results and appropriate action.  Results will be reported to the provider to communicate with the patient as soon as it is received, which has typically been 2-3 weeks after submission. The DC DOH will NOT report results directly to patients. If you have any questions regarding this important issue, you may contact the Division of Epidemiology–Disease Surveillance and Investigation: Phone: (202) 442-8141 (8:15am-4:45pm) | 1-844-493-2652 (after-hours calls) Fax: (202) 442-8060 Email: doh.epi@dc.gov Additional Resources  Information from the CDC on Zika virus: http://www.cdc.gov/zika  DCDOH Health Notice for Health Care Providers (http://doh.dc.gov/sites/default/files/dc/sites/doh/page_content/attachments/Zika%20EVD%20update%20H AN%2001_21_2016%20FINAL.pdf)  CDC MMWR: Update: Interim Guidelines for Pregnant Women During a Zika Virus Outbreak — United States, 2016 (http://www.cdc.gov/mmwr/volumes/65/wr/mm6502e1.htm)  CDC MMWR: Interim Guidelines for the Evaluation and Testing of Infants with Possible Congenital Zika Virus Infection — United States, 2016 (http://www.cdc.gov/mmwr/volumes/65/wr/mm6503e3er.htm)  CDC MMWR: Interim Guidelines for Prevention of Sexual Transmission of Zika Virus — United States, 2016 (http://www.cdc.gov/mmwr/volumes/65/wr/mm6505e1er.htm)  CDC MMWR: Possible Association Between Zika Virus Infection and Microcephaly — Brazil, 2015 (http://www.cdc.gov/mmwr/volumes/65/wr/mm6503e2.htm)  Information on the possible association with microcephaly: http://www.cdc.gov/zika/pdfs/possibleassociation-between-zika-virus-and-microcephaly.pdf  Additional instructions for submitting specimens for Zika virus testing: http://www.cdc.gov/ncezid/dvbd/specimensub/arboviral-shipping.html  Information on protection against mosquitoes: http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pretravel-consultation/protection-against-mosquitoes-ticks-other-arthropods  Information from the CDC on the 2014 EVD outbreak in West Africa: http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/. References 1. World Health Organization Western Pacific Region. Zika virus. (May 2015). Retrieved January 6, 2016, from: http://www.wpro.who.int/mediacentre/factsheets/fs_05182015_zika/en/ 2. Centers for Disease Control and Prevention. Zika virus. (December 2015). Retrieved January 6, 2016, from http://www.cdc.gov/zika/index.html

 

 

 

See: Zika Virus

The mosquito-borne disease, which is also sexually transmitted, is of greatest concern to pregnant women and those trying to become pregnant and their partners because of the devastating consequences it can have on a fetus.

Content 7

Preventing Sexual Transmission of Zika Virus

Most cases of Zika are transmitted through the bite of an infected mosquito (Aedes aegypti, the same species that can transmit dengue). However, Zika can be transmitted by two other modes: Fetal infection via the placenta of infected pregnant women; and sexual transmission from men to women.

 

 

Although Zika infection is often asymptomatic, it can cause mild fever, joint pain, and rash. Maternal infection during pregnancy has been associated with microcephaly and other congenital defects in offspring. In addition, incidence of Guillain-Barré syndrome is increased following Zika virus infection.

Data about the specific timing of Zika virus infection and risk for fetal damage continue to accrue. Among characterized cases of fetal microcephaly, symptomatic maternal infection during the first trimester of pregnancy is of greatest concern. However, lack of understanding about the duration of viremia, persistence of Zika virus in immunoprivileged sites (such as semen or placenta), and other relevant risk factors limit the ability to make definitive recommendations. The CDC's interim recommendations are as follows:

For pregnant women:

  • Healthcare providers should query pregnant women about recent travel.

  • Pregnant women who have traveled in regions where Zika virus is circulating should be tested for Zika virus infection.

  • In pregnant women with symptoms consistent with Zika virus, blood can be tested by RT-PCR. In women with histories consistent with Zika virus infection, IgM and neutralizing antibody tests are recommended. Notably, cross-reactivity with other flavivirus infections may occur.

  • Women with confirmed infection should be managed by a maternal-fetal medicine provider or an infectious disease specialist with expertise in pregnancy.

  • Women who are pregnant or considering pregnancy should consider postponing travel to areas with Zika virus transmission.

For women and men considering travel to areas with known Zika virus transmission:

  • Mosquitoes that transmit Zika virus are daytime biters; thus, bed nets alone are insufficient.

  • Long pants and long sleeves are recommended to reduce risk for mosquito bites.

  • Permethrin-treated clothes and air conditioning are beneficial.

  • Insect repellent containing DEET, picaridin, and IR3535 should be applied per label.

Whereas half of pregnancies in the U.S. are unintended, many countries in Central and South America lack readily accessible birth control (especially highly effective methods), further hampering contraception. Men returning from areas with Zika virus transmission — and whose partners are pregnant — should abstain from sexual intercourse or use condoms consistently throughout the pregnancy.

- See more at: http://www.jwatch.org/na40455/2016/02/11/preventing-sexual-transmission-zika-virus?query=etoc_jwwomen&jwd=000013567259&jspc=TS#sthash.axiuyIKZ.dpuf

 “Interim Guidelines for Pregnant Women During a Zika Virus Outbreak” on its website.2 The guidance can be distilled down to four basic points:

1. Include travel history and future travel plans during all visits with pregnant patients.

2. Pregnant women should postpone any travel to locations wherein Zika transmission is occurring.

  • Infection can occur in any trimester.
  • It is still unclear if Zika causes fetal loss and to what extent it leads to microcephaly.

3. Should travel be necessary, strict adherence to mosquito avoidance must be followed.

4. Management for pregnant women with travel to areas of ongoing transmission includes:

  • Fetal ultrasound for all to assess for microcephalus and/or intracranial calcifications.
  • Asking about Zika virus disease symptoms: acute fever, maculopapular rash, arthralgia, conjunctivitis.
  • Testing for infection in those with two or more symptoms during travel or within 2 weeks of travel (any testing should be done in conjunction with your public health department).
  • A nice management flow sheet is available at: http://www.cdc.gov/mmwr/volumes/65/wr/mm6502e1er.htm.

Finally, keep in mind that Zika virus disease represents a rapidly evolving situation. Information and guidance are likely to change and be updated as we learn more of this mosquito-borne infection. Current information is easily available at the CDC website.3

Anna Wald, MD, MPH

References

  1. Prevention C. Travel Health Notices | Travelers' Health | CDC. 2016. Available at: http://wwwnc.cdc.gov/travel/notices/. Accessed January 27, 2016.
  2. Petersen E, Staples J, Meaney-Delman D, et al. Interim guidelines for pregnant women during a Zika virus outbreak—United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65(2):1-4.
  3. Cdc.gov. Zika Virus| Zika virus | CDC. 2016. Available at: http://www.cdc.gov/zika/. Accessed January 27, 2016.

Zika virus infection is widespread in Latin America, with some cases also reported in the U.S. and elsewhere.

Zika is transmitted by aedes aegypti mosquitoes, the same mosquitoes that transmit Dengue fever and Chikungunya. These mosquitoes breed in stagnant water

We also know that transmission from mother to child appears to pose serious risks to the infant, including microcephaly.

{Argument for Reproductive Health} In many of the countries where Zika is taking hold, poor women, adolescent girls, and women from marginalized communities simply do not have a choice about sexual relations, nor do they have comprehensive sexual education or secure access to contraception, so they cannot control whether they will get pregnant.

Some of the countries in which the virus has broken out have the most restrictive abortion laws in the world, courtesy of governments that are handmaidens to religious ideology rather than protectors of reproductive rights. Take El Salvador, where there are no exceptions for the criminalization of abortion. The trend there is to prosecute women for infanticide (which carries a much stiffer penalty) than for having procured an abortion. Abortion law in Brazil, where Zika has to date had the largest number of cases, is being challenged presently, and no doubt other challenges will follow.

But we might all ask: Why do poor women and girls (and potentially their children) need to be put through this needless suffering, rather than ensure access to abortion where it is legal and also reform laws and policies to eliminate structural discrimination against women who are without access to contraception, abortion and sexuality education that meets internationally accepted standards of human rights?

As Zika demonstrates, precisely because of our reproductive capacities, it is women in particular who experience their poverty and marginalization through their contact with indifferent health systems. It is women who again will pay the greatest consequences of the impacts of the lack of public health measures, inadequate social protection, and discriminatory laws and, to boot, may be blamed for “getting themselves pregnant.”

The efforts of President Juan Manuel Santos of Colombia and other regional leaders to bring health ministers together, and of WHO’s quick response should be applauded. But the response to Zika needs to go beyond immediate containment and vector control, and international health “security” to push for meaningful government commitments necessary to address underlying social conditions and discrimination against women.

In the US, mosquitoes that transmit Zika virus, Aedes aegypti and albopictus, are present year round in Florida and seasonally in about a quarter of the states. “It is pretty clear that it will be coming.… We need to take precautions until treatments or preventives are available,” he said. In addition, child neurologists need to be able to recognize congenital Zika syndrome. “It is entirely possible for us to do so,” Dr. Dobyns said. “You do not even need viral titers in the more classically affected children.”

Reference

serologic testing to asymptomatic pregnant women (women who do not report clinical illness consistent with Zika virus disease) who have traveled to areas with ongoing Zika virus transmission. Testing can be offered 2–12 weeks after pregnant women return from travel.1

 

A 54-year-old man presents to his clinician complaining of polyuria. He states that he must get up three or four times each night to urinate. He also notes frequent thirst. He denies polyphagia, urinary urgency, difficulty initiating urination, or postvoid dribbling. His medical history is notable only for bipolar disease. He has a long-standing history of noncompliance with medications for this disease, with frequent hospitalizations for both mania and depression, but has been stable on lithium for the past 6 months. He denies any symptoms of mania or depression at this time. He takes no other medications. Family history is notable for depression and substance abuse. The patient has a history of polysubstance abuse but has been “clean and sober” for the past 6 months. On examination, the patient's vital signs are within normal limits. Head-neck examination reveals slightly dry mucous membranes. Rectal examination reveals a normal prostate without masses. The remainder of his examination is unremarkable. Urinalysis reveals dilute urine without glycosuria or other abnormality. Serum electrolytes reveal a mildly increased sodium level. A diagnosis of diabetes insipidus is entertained.

 

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