MMWR: Local Transmission Of Zika Virus In Puerto Rico

Credi MMWR

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The CDC has published, late this afternoon, an extensive MMWR review of local acquisition of the Zika virus in the U.S. Territory of Puerto Rico - to date involving 30 individuals - including one pregnant woman.


The review, charts, and map are far too large to excerpt here effectively, so I'll simply direct my readers to follow the link. I have excerpted the summary.

Local Transmission of Zika Virus — Puerto Rico, November 23, 2015–January 28, 2016
 
FEBRUARY 12, 2016
On December 31, 2015, the Puerto Rico Department of Health reported the first locally acquired case of Zika virus disease in a jurisdiction of the United States in a patient from southeastern Puerto Rico. Zika virus is expected to continue to spread throughout the territory, and the 3.5 million residents of Puerto Rico, including approximately 43,000 pregnant women per year, are at risk for Zika virus infection.

Early Release / February 12, 2016 / 65(6);1–6

• PDF [529 KB]

Dana L. Thomas, MD^1,2; Tyler M. Sharp, PhD³; Jomil Torres, MS¹; Paige A. Armstrong, MD⁴; Jorge Munoz-Jordan, PhD³; Kyle R. Ryff, MPH¹; Alma Martinez-Quiñones, MPH⁵; José Arias-Berríos, MD⁶; Marrielle Mayshack^1,7; Glenn J. Garayalde, MD⁸; Sonia Saavedra, MD, PhD⁸; Carlos A. Luciano, MD⁶; Miguel Valencia-Prado⁵; Steve Waterman, MD³; Brenda Rivera-García, DVM¹

Summary

 

What is already known about this topic?Zika virus emerged in the Region of the Americas in mid-2015, and since then, outbreaks have occurred in multiple South American and Caribbean countries and territories. Zika virus infection appears to be related with increased risk for fetal microcephaly and Guillain-Barré syndrome.
 

What is added by this report?The first locally acquired case of Zika virus disease in Puerto Rico was identified in early December 2015. During the subsequent months, 29 additional laboratory-confirmed cases have been detected, including in one pregnant woman and in a man with Guillain-Barré syndrome.

What are the implications for public health practice?Clinicians in Puerto Rico and other clinicians evaluating patients with recent travel to Puerto Rico should report all cases of suspected Zika virus disease to public health authorities. Residents of and visitors to Puerto Rico should strictly follow steps to avoid mosquito bites including using air conditioning or window and door screens when indoors, wearing long sleeves and pants, using permethrin-treated clothing and gear, and using insect repellents. When used according to the product label, Environmental Protection Agency-registered insect repellents are safe for pregnant women.

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Brazil MOH: Epi Week 5 Microcephaly report

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The weekly reporting on microcephaly cases from Brazil's MOH started out being posted  on Tuesdays last December, shifted to Wednesdays in January, while this week's report has run the latest to date - appearing on Friday.

With the removal of both confirmed and discarded cases from the Total Under Investigation each week, the numbers tend to bounce around.  But this week's report adds 296 new cases to the investigation, leaving 3862 cases under investigation.

Out of 1,227 cases that have been investigated, 462 (37.6%) have been confirmed as microcephaly or other CNS disorders. A state-by-state listing of cases can be found at the link below.

Ministry of Health investigates 3,852 suspected cases of microcephaly in the country

New report shows that 462 cases have been confirmed to microcephaly or other disorders of the central nervous system, 41 with respect to the Zika virus. Notified, they were discarded 765
 
The Ministry of Health and the states investigating 3,852 suspected cases of microcephaly across the country. The new report released on Friday (12) points out, too, that 462 cases have had microcephaly confirmation and / or other disorders of the central nervous system, and 41 with respect to the Zika virus. This week 24 new cases were confirmed, compared with the previous week.

Other 765 cases reported were discarded because they had normal exams, or submit microcefalias and / or changes in the central nervous system by an infectious causes. In all, 5,079 suspected cases of microcephaly have been recorded since the start of the investigation in October 22, 2015 until February 6, 2016. Of this total, 62.5% of cases (3,174) were reported in 2015 and 37.5% ( 1,905) in the year 2016.

The state of Pernambuco remains with the largest number of confirmed cases in relation to the Zika virus (33), followed by Rio Grande do Norte (4), Paraíba (2) and Ceará and Pará with one case each. Amapá and Amazonas are the only states of the federation which has no record of suspected cases of microcephaly.

In total, 91 deaths were reported by microcephaly and / or alteration of the central nervous system after birth (stillbirth) or during pregnancy (miscarriage). Of these, 24 were investigated and confirmed for microcephaly and / or alteration of the central nervous system, of which eight were discarded. Another 59 are still under investigation.

It should be noted that the Ministry of Health is investigating all cases of microcephaly and other disorders of the central nervous system, informed by the states and the possible relationship with the Zika virus and other congenital infections. Microcephaly can be caused by various infectious agents beyond Zika, such as syphilis, toxoplasmosis, Other Infectious Agents, Rubella, Cytomegalovirus and Herpes Viral.

According to the report, the 462 confirmed cases were reported in 175 municipalities in 13 states: Alagoas, Bahia, Ceará, Espírito Santo, Goiás, Mato Grosso do Sul, Pará, Paraíba, Pernambuco, Piauí, Rio Grande do Norte, Rio de Janeiro and Rio Grande do Sul. the Northeast region has the largest number of confirmed cases and Pernambuco continues with the highest number of confirmed cases (167), followed by the states of Bahia (101), Rio Grande do Norte (70), Paraíba (54), Piauí (29) and Alagoas (21).

So far, they are with indigenous circulation of Zika virus 22 units of the federation. They are: Goiás, Minas Gerais, Federal District, Mato Grosso do Sul, Roraima, Amazonas, Pará, Rondônia, Mato Grosso, Tocantins, Maranhão, Piauí, Ceará, Rio Grande do Norte, Paraiba, Pernambuco, Alagoas, Bahia, Espírito Santo , Rio de Janeiro, Sao Paulo and Parana. 

(Continue . . . )

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WHO Update : Yellow Fever Outbreak In Angola

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Over the past couple of days there have been media reports of another arbovirus outbreak in west central Africa (see Yellow fever outbreak kills 37 in Angola) vectored by the same mosquito as the Zika (and Dengue & CHKV) virus.

Yellow fever is currently a threat to 900 million inhabitants of Africa and parts of South America where it remains endemic and occasionally epidemic.

First the WHO update on the Angola outbreak, and then I'll return with a bit more on the subject.

Yellow Fever – Angola

12 February 2016 - On 21 January 2016, the National IHR Focal Point of Angola notified WHO of an outbreak of yellow fever. 

The first cases were identified in the district of Viana (Luanda province) on 5 December 2015. Yellow fever infection was initially confirmed in three patients by polymerase chain reaction at the Zoonosis and Emerging Disease Laboratory of the National Institute for Communicable Diseases in Johannesburg, South Africa and at the Pasteur Institute in Dakar, Senegal. 

As of 8 February, a total of 164 suspected cases and 37 deaths had been reported in Angola. The majority of cases (n=138) had been reported in the province of Luanda. Other affected provinces include Cabinda, Cuanza Sul, Huambo, Huila and Uige. Suspected cases are undergoing laboratory testing in order to rule out other aetiologies and cross reactions with yellow fever.

Public health response

The national task force has been activated to control the outbreak. Health authorities in Angola are implementing a number of control and response activities, including coordination, clinical case management, enhanced surveillance, laboratory testing, social mobilization and vector control. Epidemiological and entomological investigations are ongoing in the main affected areas. On 3 February, the first round of immunization campaign started in Luanda. 

WHO has deployed three experts to provide operational support. In addition to financial support, technical directives and guidelines have been shared with country officials to improve the quality of the response.

On 2 February, an immunization campaign was launched in Luanda. The campaign will initially cover a target population of 1,578,085 in Viana.

WHO risk assessment

In the affected districts of Luanda, there is a high density of Aedes Aegypti, the primary vector of yellow fever; consequently, the risk of spread to unaffected districts is high. This risk is further exacerbated by the high proportion of susceptible individuals, as the only protected groups are the citizens with international vaccination cards and those children that have been vaccinated against yellow fever since 2008. WHO continues to monitor the epidemiological situation and conduct risk assessment. WHO does not recommend any travel or trade restriction to Angola based on the current information available.

Background

Yellow fever is an acute viral haemorrhagic disease transmitted by infected mosquitoes. Up to 50% of severely affected persons without treatment will die from yellow fever. There are an estimated 130,000 cases of yellow fever reported yearly, causing 44,000 deaths worldwide each year, with 90% occurring in Africa. There is no specific treatment for yellow fever. Treatment is symptomatic, aimed at reducing the symptoms for the comfort of the patient. Vaccination is the most important preventive measure against yellow fever. Since the second half of 2015, yellow fever virus circulation has been reported in Mali and Ghana.

While Yellow Fever has been successfully eradicated from North America and Europe for decades, the mosquito vectors that transmit the virus are still present in some regions.

And just as with Dengue, Chikungunya, Malaria,  and most recently Zika, the potential for limited re-introduction of Yellow Fever is not nil.  

A 2010 Eurosurveillance Journal devoted an entire issue to The Threat Of Vector Borne Diseases, including making the case for the reintroduction of  Yellow fever and dengue: a threat to Europe? by P Reiter (excerpt below).

Yellow fever and dengue: a threat to Europe?

P Reiter ()¹

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The introduction and rapidly expanding range of Aedes albopictus in Europe is an iconic example of the growing risk of the globalisation of vectors and vector-borne diseases. The history of yellow fever and dengue in temperate regions confirms that transmission of both diseases could recur, particularly if Ae. aegypti, a more effective vector, were to be re-introduced.  The article is a broad overview of the natural history and epidemiology of both diseases in the context of these risks.

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(SNIP)

The history of dengue and yellow fever in Europe is evidence that conditions are already suitable for transmission. The establishment of Ae. albopictus has made this possible, and the possibility will increase as the species expands northwards, or if Ae. aegypti is re-established.

And in 2013 Peter Hotez - Dean of the National School of Tropical Medicine at Baylor College of Medicine - and Kristy Murray, an associate professor of pediatrics at Baylor College of Medicine who studys mosquito-borne diseases, penned a PLoS Blog entitled.  

Could Yellow Fever Return to the United States? 

Posted December 5, 2013 by Peter Hotez and Kristy Murray in General, Neglected Diseases

 

Peter Hotez and Kristy Murray from Baylor College of Medicine highlight the potential for yellow fever to return to the southern cities of the United States

Spolier alert, it could.


A reminder, that when it comes to re-emerging infectious diseases - even in areas that for decades have been immune - one should never say `never'.

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WHO Update: Guillain-Barre Syndrome (GBS) In Columbia & Venezuela

Credit CDC

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On Monday, in Guillain-Barre syndrome: The Other Zika Concern, we looked at growing  evidence that Zika virus infection might - in rare instances -  provoke an autoimmune disease called Guillain-Barre Syndrome that can present with muscle weakness and even paralysis.

I wrote about the first sign that Zika might be capable of such a thing nearly two years ago in Zika, Dengue & Unusual Rates Of Guillain Barre Syndrome In French Polynesia. In March 2014 the journal Eurosurveillance carried a Rapid Communications describing the first case and reporting a 20-fold increase in GBS during their Zika outbreak.

While a handful of cases of GBS have been linked to Dengue and Chikungunya, neither have been viewed as a strong risk factor. But once again we seem to be seeing an increase in Guillain-Barre Syndrome in countries (Brazil, El Salvador, Columbia, and Venezuela) where the Zika virus is currently circulating. 


While a Zika-GBS link has yet to be fully established, the evidence seems to grow stronger with each passing day.  This update on recent surges in GBS in South America comes from the World Health Organization.

Guillain-Barré syndrome – Colombia and Venezuela

Disease Outbreak News
12 February 2016 

Between 30 January and 2 February 2016, the National IHR Focal Points of Colombia and Venezuela informed PAHO/WHO of increases in the number of Guillain-Barre Syndrome (GBS) cases recorded at the national level.

Colombia

From epidemiological week (EW) 51 of 2015 to EW 3 of 2016, 86 GBS cases were reported. On average, Colombia registers 242 GBS cases per year or approximately 19 cases per month or 5 cases per week. The 86 GBS cases reported in those 5 weeks is three times higher than the averaged expected cases of the 6 previous years.

Initial reports indicated that all the 86 reported GBS cases presented with symptoms compatible with a Zika virus infection. Of the 58 cases for which information is available, 57% were male and 94.8% were 18 years old or older.

Venezuela

From 1 January to 31 January 2016, 252 GBS cases with a spatiotemporal association to Zika virus were reported. While cases were recorded in the majority of the federal territories of the country, 66 were detected in the state of Zulia, mainly in the Maracaibo municipality.

Preliminary analysis of the GBS cases in the state of Zulia indicates that the 66 cases originated from six municipalities. Of the 66 cases, 30% were 45 to 54 years old and 29% were 65 years or older; 61% were male and 39% were female. A clinical history consistent with Zika virus infection was observed in the days prior to onset of neurological symptoms in 76% of the GBS cases in the state of Zulia. Associated comorbidities were present in 65% of the cases. Patients were treated with plasmapheresis and/or immunoglobulin. In some cases, according to medical indication, both treatments were used following the treatment protocol established by the Ministry of Popular Power for Health.

Zika virus infection was confirmed by polymerase chain reaction in three GBS cases, including a fatal case with no comorbidities. A total of three cases presenting with other neurological disorders were also biologically confirmed. 

Between late November to 28 January 2016, 192 cases of Zika virus infection were laboratory confirmed through reverse transcription polymerase chain reaction. Of the 192 cases, 110 (57%) are from the state of Zulia.

WHO risk assessment

Zika virus infection has been laboratory confirmed in only three of the reported GBS cases from Venezuela, while the infection has not been detected in any of the GBS cases from Colombia. Although the cause of the rise in GBS cases has not yet been established, similar increases have been observed in other countries, notably El Salvador and Brazil (see DONs published on 21 January and 8 February 2016, respectively). Further investigations are needed to identify the potential role of previous infections known to be associated, or potentially associated, with GBS.

WHO recommends Member States affected or susceptible to Zika virus outbreaks to:

• monitor the incidence and trends of neurological disorders, especially GBS, to identify variations against their expected baseline values;
• develop and implement sufficient patient management protocols to manage the additional burden on health care facilities generated by a sudden increase in patients with Guillain-Barre Syndrome;
• raise awareness among health care workers and establish and/or strengthen links between public health services and clinicians in the public and private sectors.

(Continue . . .)

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EID Journal: Zika Virus Detection in Semen

Credit CDC PHIL

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Although there was only one case on record at the time (from 2008 see Probable Non–Vector-borne Transmission of Zika Virus, Colorado, USA), in late January the UK PHE Warned On Potential Sexual Transmission Of Zika strongly recommending that:

Sexual transmission of Zika virus has been recorded in a limited number of cases, and the risk of sexual transmission of Zika virus is thought to be very low. However, if a female partner is at risk of getting pregnant, or is already pregnant, condom use is advised for a male traveller :

• for 28 days after his return from a Zika transmission area if he had no symptoms of unexplained fever and rash
  
• for 6 months following recovery if a clinical illness compatible with Zika virus infection or laboratory confirmed Zika virus infection was reported

Less than a week later, a second case was confirmed (see Dallas, Texas: DCHHS Confirms Locally Acquired Sexually Transmitted Zika Infection), and soon other public health agencies were issuing similar advice.

Today we may know what prompted the UK's initial strong recommendations. 

A letter, published ahead of print today in the CDC's EID journal, describes the detection of ZIKV by rRT-PCR in a 68 year old man's semen by the UK's PHE in 2014, more than 2 months after the onset of his illness.


While live virus was not cultured from the sample, it suggests that sexual transmission may be possible weeks or even months after initial infection.  Not unlike what we've seen (albeit, very rarely) with Ebola.


While the persistence of ZIKV in semen for weeks or months increases the risks of sexual transmission, the mosquito-vector remains the primary way the virus is transmitted to humans.

Volume 22, Number 5—May 2016

Letter

Detection of Zika Virus in Semen

Atkinson B, Hearn P, Afrough B, Lumley S, Carter D, Aarons EJ, et al.

To the Editor: As an increasing number of autochthonous Zika virus (ZIKV) infections are reported from several South America countries (1), we read with interest the report from Musso et al. on the potential sexual transmission of ZIKV (2). We report additional evidence for this potential route of transmission after identification of an imported case of ZIKV infection into the United Kingdom.

After an outbreak alert for ZIKV in French Polynesia, active ZIKV screening was implemented at Public Health England (Porton Down, United Kingdom). In 2014, a 68-year-old man had onset of fever, marked lethargy, and an erythematous rash 1 week after returning from the Cook Islands. Serum samples taken 3 days into the febrile illness tested negative for dengue and chikungunya viruses by real-time reverse transcription PCR (rRT-PCR). Test results for dengue virus IgM and chikungunya virus IgM also were negative; a test result for dengue virus IgG was indeterminate.

An rRT-PCR test result for ZIKV (3) was positive and indicated a crossing threshold value of 35 cycles. This low viral load, commonly observed even in the acute phase of disease (3), meant that attempts to obtain sequence data were unsuccessful. 

Convalescent-phase serum, urine, and semen samples were requested; only semen was positive for ZIKV by rRT-PCR, , at 27 and 62 days after onset of febrile illness. These results demonstrated stronger signals than those obtained in tests of the original serum sample, with crossing threshold values of 29 and 33 cycles, respectively. ZIKV-specific plaque reduction neutralization test results were positive on convalescent-phase serum samples.

Although we did not culture infectious virus from semen, our data may indicate prolonged presence of virus in semen, which in turn could indicate a prolonged potential for sexual transmission of this flavivirus. Moreover, these findings could inform decisions regarding what control methods are implemented and which specimen types are best suited for diagnostic detection.

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WHO: Updated Information For Travelers Visting Zika Affected Countries

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The World Health Organization has updated their travel information, once again emphasizing that WHO is not recommending any travel or trade restrictions related to Zika virus disease.

The remainder of their advice, when compared to that which we've seen issued by many other public health agencies, comes across as noticeably less urgent in tone.

While the CDC strongly urges pregnant women avoid travel to Zika prone areas, the WHO advises pregnant women consult their health care provider first, and `consider delaying travel'. 

Information for travellers visiting Zika affected countries

Updated

12 February 2016 

Travellers should stay informed about Zika virus and other mosquito-borne diseases and consult their local health or travel authorities if they are concerned.

Based on available evidence, WHO is not recommending any travel or trade restrictions related to Zika virus disease. Countries reporting sporadic Zika infections in travellers arriving from affected countries pose little, if any, risk of onward transmission.

As a precautionary measure, some national governments may make public health and travel recommendations to their own populations, based on their assessment of the available evidence and local risk factors.

Precautionary measures for pregnant women and women considering pregnancy

Based on the latest evidence that Zika virus infection during pregnancy may be linked to microcephaly in newborns, WHO is issuing further precautionary travel advice to women who are pregnant and their sexual partners.

Women who are pregnant should discuss their travel plans with their health care provider and consider delaying travel to any area where locally acquired Zika infection is occurring. 

Zika virus is spread by mosquitoes, and not by person-to-person contact, though a small number of cases of sexual transmission have been documented.

Zika has been found in human semen. Two reports have described cases where Zika has been transmitted from one person to another through sexual contact. 

Until more is known about the risk of sexual transmission, all men and women returning from an area where Zika is circulating - especially pregnant women and their partners - should practice safe sex, including through the correct and consistent use of condoms.

All travellers, including pregnant women, going to an area where locally acquired Zika infection is occurring should adhere closely to steps that can prevent mosquito bites during the trip. These include:

• using insect repellent: repellents may be applied to exposed skin or to clothing, and should contain DEET. Repellents must be used in strict accordance with the label instructions;
• wearing clothes (preferably light-coloured) that cover as much of the body as possible;
• using physical barriers such as screens, closed doors and windows;
• sleeping under mosquito nets, especially during the day, when Aedes mosquitoes are most active; and
• identifying and eliminating potential mosquito breeding sites, by emptying, cleaning or covering containers that can hold even small amounts of water, such as buckets, vases, flower pots and tyres.

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Saudi MOH Reports 2 MERS Cases

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After going 8 days without reporting any MERS cases, the Saudi MOH announces two today, one of which (M,34, Najran) has already died.  The second case (M,41, Al-Kharj) is listed in stable condition.

The likely exposure of the fatal case is still under investigation, but the Al Kharj case is listed as a Household Contact - Indirect Contact with Camel. It is likely this person is connected to the 47 y.o. male with camel contact from Al-Kharj reported on January 27th.
 

In what is hopefully part of an ongoing trend, Saudi Arabia has now gone more than four months without reporting a large hospital-related MERS outbreak. The last one of any size was in Riyadh last summer.  

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