Zika Virus Infection

1. Zika Virus Infection Thomas M. File, Jr. M.D., M.Sc. Chair, Infectious Disease Division Summa Health System; Professor of Internal Medicine, Chair Infectious Disease Section Northeast Ohio Medical University

5. Fever in Traveler returning from Caribbean • Returning traveler from the Caribbean(5 days) • Within 24 hours c/o pain to back of knees, both ankles and feet, wrists and hands-symmetric, no swelling nor erythema, lasted 3-4 days • Severe spinal pain, inability to stand upright -3 days • Fevers –constant for up to 72 hours 101-102F • Malaise, myalgia, fatigue for 1 week • 2-3 days later, faint erythema to trunk, followed by photosensitivity rash to arms face legs-transient pruritus • No headaches, URI symptoms

6. Chikungunya • Viral infection • No vaccine or treatment • No person-to-person transmission • Mosquito vectors • Aedes aegypti or Aedes albopictus widespread • Mosquitoes can “hitchhike”

8. Chikungunya • The mosquitoes • Aedes species; same types for dengue virus • Bite mostly during the daytime • Symptoms • Usually begin 3‒7 days after being bitten by an infected mosquito • Most common symptoms are fever and severe joint pains, often in the hands and feet • Joint pains persist in 50% for > 1 year • Other symptoms may include headache, muscle pain, joint swelling, or rash

9. Chikungunya • Sudden high fever (usually >102º F) which may be continuous or intermittent • Severe joint pain that commonly involves the hands and feet • Joint swelling • Back pain • Rash usually 2-5 days after fever starts • Other symptoms may include headache, body ache, nausea, vomiting, and redness around the eyes. In unusual cases, infection can involve the brain, eyes, heart, kidney and other organs.  • Fatal infections are rare, however many patients have chronic joint pain, arthritis, loss of energy and depression lasting weeks to years.

10. Differential diagnosis • Chikungunyavs Dengue viral fever • Dengue more pronounced retro-orbital pain • More commonly hypotension and mild bleeding complications • Fatigue can last for months • Associated with higher mortality • ?influenza-like, but no URI symptoms • Outbreak Dengue in Hawaii (Nov, 2015, Big Island)

11. Diagnostic testing • Performed on the 3rd day given persistent symptoms • CBC, mild lymphopenia, mild thrombocytopenia • LFT not done • Mild CPK elevation • Chikungunya PCR+ • Other options: paired sera for Chikungunya IgM

12. Chikungunya Treatment/Prevention • No medication to treat or prevent infection • Vaccine under development • Reduce mosquito exposure • Use air conditioning or window/door screens • Use mosquito repellents on exposed skin. Repellents containing DEET, picaridin, IR3535, and some oil of lemon eucalyptus and para-menthane-diol products provide long lasting protection. • Wear long-sleeved shirts and long pants • Empty standing water from outdoor containers • Support local vector control programs

13. Flaviviridae virus family; related to dengue, West Nile, Chikungunya • Started Uganda; new to West Hemisphere, Fla….. • Transmission: Mosquitoes, Sexual contact, ?other • Incubation: 2-12 days • Only 1 in 5 people infected with Zika virus experience symptoms • fever, rash, joint pain and conjunctivitis, and sometimes headaches, muscle pain and vomiting. The illness lasts about a week. • linked to some alarming complications-microcephaly in fetuses of infected pregnant women; Guillan Barre Syndrome……. • Test: PCR of blood (within 7-14 days illness); Serology (after 14 days)

16. TRANSMISSION

17. Zika Virus Clinical Course • Clinical course usually mild • Symptoms last several days to a week • Severe disease requiring hospitalization infrequent • Fatalities rare • Neurologic sequelae uncommon

18. Neurologic manifestations of Zika virus • Burden higher than Microcephaly • Other Childhood concerns • Other neurological sequelae: • GBS • Encephalitis • Myelitis • Acute disseminated encephalomyelitis (ADEM) • Opsoclonus-myoclonus-ataxia syndrome( OMS) • James J. Sejvar, MD, Neuroepidemiologist CDC. Nov 11, 2016

19. ZIKA SYMPTOMS Typically starts on face ; spreads

21. NEJM March 3, 2016

23. ZIKA: Therapy Prevention

30. 72 Pregnant women + Zika; 5-38 wks gestation • Pred features; • pruritic descendng rash (maculopapulrar), arthralgia, HA; 28% fever, lymphadenopthy • 42 with fetal US • Abn in 12 (29%) • Fetal death-2 • Growth restriction with or without microcephaly- 5 • CNS lesions- 7; ABN cerebral or umbilical artery flow-7 • Conclusion: Despite mild clinical symptoms, ZIKV infection during pregnancy appears to be associated with grave outcomes, including fetal death, placental insufficiency, fetal growth restriction, and CNS injury NEJM March 3, 2016

31. NEJM March 3, 2016

32. Zika and Microcephaly: US • Report from CDC 2/25/2016 • 9 woman with + tests (of 257 tested) • 3 delivered: 2 healthy, 1 microcephaly • 2 had miscarriages • 2 abortions: one with microcephaly • 2 pregnancies continuing • 2 of nine delivered healthy babies, but two still pregnant • 2 confirmed microcephaly

33. Zika: US • Report 10/26/2016 • Total 32,814 • Locally acquired: 28,289 • 99% in territories: PR, VI…. • 139 in FLA • Travel related 4048 • Preg outcomes in 50 US States • 25 births with defects.

35. CDC Recommendations: Pregnancy • If pregnant avoid travel to areas of Zika infection • Male partners to areas should abstain or use condoms during entire pregnancy if traveled to area of Zika infection; avoid impregnation for 6 months • If Pregnant and has traveled to area of Zika infection • See algorithm next slide • If not pregnant but child bearing age and going to area of Zika infection • Use reliable birth control (50% pregnancies in US unplanned) • Mosquito avoidance • Avoid pregnancy 2 months

37. ZIKA Vaccine • Under Development • In June 2016 the FDA granted the first approval for a human clinical trial for a Zika vaccine.

38. Healio Outbreak Tracker. Nov 24, 2016

39. Healio Outbreak Tracker. Nov 28, 2016