Zika virus

Zika

1. ZIKA VIRUS Dr. Herminio Olivero ObGyn , FACOG

2. What is ZIKA virus? Mosquito bourne flavivirus Transmitted by Aedes Aegyptus mosquito Found throughout the region of The Americas Dengue and Chikungunya both transmitted by these mosquitoes

3. Zika Virus Humans are primary host 80% asymptomatic Symptomatic disease mild compared to dengue and chikungunya Acute onset fever Macular rash Arthralgia Non-purulent conjunctivitis Symptoms last days-1 wk Hospitalization/fatalities rare

4. ZIKA Virus No vaccine No prophylaxis to travelers Mosquitoes bite mostly during daylight Long sleeve shirts/pants Repellants with DEET/IR 3535/ picaridin safe during pregnancy Infected persons to avoid mosquito exposure during 1 st week of illness to avoid human to human transmission

5. ZIKA Virus No treatment Supportive Rest Fluid Analgesic/antipyretic Avoid aspirin, NSAID until Dengue ruled out

6. ZIKA Virus infection Intrauterine transmission Intrapartum transmission RNA detected in breast milk but no documented transmission

7. ZIKA outbreak in Brasil Zika virus identified in specimens of Brain tissue Placenta/amniotic fluid Infants with microcephaly

8. ZIKA virus testing No commercial testing available Diagnosis by molecular and serologic testing RT-PCR for viral RNA IG-Immunoglobulin MELISA for Zika activity PRNT-plasma reduction neutralization test-for Zika antibodies Testing performed at CDC

9. CDC guidelines for US health care providers caring for pregnant women during ZIKA virus outbreak Serologic testing for asymptomatic pregnant women exposed Offered 2-12 weeks after return from travel Pregnant women who reside in areas with ongoing outbreak Testing at initiation of PNC and at mid-second trimester With negative Zika virus IGM testing Routine PNC US 18-20 wks gestation for fetal anatomy US later in pregnancy as follow up

10. Pregnant women with positive or inconclusive ZIKA virus test results Monitor fetal anatomy Monitor fetal growth every 3-4 weeks Referral to maternal-fetal specialists Testing at time of delivery Testing of cord tissue for Zika virus RNA If fetal loss Zika virus RT-PCR of fetal tissue, umbilical cord and placenta

11. Preconceptive care for women in areas of active Zika virus transmission Plan pregnancy Personal decision Contraceptive methods Assessment of risk Signs and symptoms of Zika

12. Men and Women diagnosed with ZIKA CDC recommends Women to wait 8 weeks before trying to get pregnant Men to wait at least 6 months after symtpons No reported cases of Zika virus transmission through assisted reproductive technology (ART) No evidence of increased risk for future pregnancies

13. Prenatal diagnosis of microcephaly Ultrasound is safe during pregnancy Preventive fetal ultrasound at 18-20 weeks Ultrasound findings associated with Zika Microcephaly intracranial calcification Brain and eye anomalies

14. Ultrasound accuracy of microcephaly Accuracy to detect microcephaly associated to Zika virus depends on many factors Severity of microcephaly Maternal obesity Gestational age Equipment Expertise Fetal MRI is last screening tool

15. M icrocephaly Occipitofrontal circumference less than 3% If mother potentially infected infant should be tested Test infant serum for Zika virus RNA/ Zika virus IgM and ab’s Initial sample from umbilical cord or directly from infant within 2 days after birth If CSF obtained for other studies-perform above testing Consider histopathologic evaluation of placenta and umbilical cord Test mother’s serum if not done during pregnancy

16. Guidelines for infants with microcephaly

17. Indications for testing infants Infant with microcephaly or intracranial calcification born to women who travel or reside in area with active Zika virus transmission Infant born to mothers with positive or inconclusive tests for Zika virus

18. Infants with possible Zika virus infection Comprehensive physical evaluation Head circumference, length and weight for gestational age Evaluate for neurologic abnormalities Dysmorphic features, splenomegaly, hepatosplenomegaly, rash or other skin lesions Cranial ultrasound Hearing – evoked optoacoustic emissions testing or ABR

19. Infants with possible Zika virus infection Ophtalmologic evaluation If microcephaly/intracranial calcifications Geneticist evaluation Pediatric neurologist Test for other congenital infections CBC, liver function, imaging studies If positive or inconclusive Zika virus testing-report case to state health department and assess for long term sequelae

20. Management and prevention of congenital Zika virus infection No antiviral treatment available Supportive Specific medical and neurodevelopmental needs Encourage breastfeeding To prevent congenital Zika – prevent maternal infection

21. Orden administrativa num 345 2 de febrero 2016 Para ordenar a los proveedores medicos y aseguradoras sobre cernimiento y cuidado pre y post natal a toda embarazada Declaro estado de emergencia como resultado del Virus ZIKA en Puerto Rico, ordenando a todos los profesionales de la salud notificar todo caso sospechoso y/o confirmado de ZIKA Todo proveedor medico que evalue a una mujer embarazada que presente sintomas asociados al ZIKA se le ordenara realizarse la prueba de PCR-la aseguradora cubrira la toma de muestra

22. Orden administrativa num 345 Toda mujer embarazada que no presente sintomas , tendra la opcion de hacerse pruebas serologicas para ZIKA y dengue en aquellas areas de alta densidad de transmission segun informes epidemiologicos semanales emitidos por el Departamento de Salud . Las pruebas seran enviadas al Departamento de Salud y la toma de muestra sera cubierta por la aseguradora . Si la prueba arroja un resultado negative se puede considerar repetir la prueba en el Segundo trimestre

23. Orden administrativa num 345 Si resultado fuese positivo el cuidado prenatal comprende lo siguiente en adicion al cuidado prenatal preventivo Sonogramas cada 4 semanas Ofrecer amniocentesis despues de semana 15 pesando riesgo con su proveedor y muestra sera enviada al Dpt de Salud-cubierto por aseguradora Cuido post natal para madre y bebe con resultado positivo Si nace bebe con microcefalia se recomienda prueba de PCR a cordon umbilical y suero

24. ZIKA en Puerto Rico Casos reportados en : San Juan, Carolina, Trujillo Alto, Carolina, Caguas, Gurabo , Juncos, Las Piedras , Luqillo , Naguabo , Humacao , Ceiba , Guanica Mayores casos en Fajardo

25. ZIKA en Puerto Rico Perfil de casos - casos confirmados 19 Edad mediana 42yrs ( rango de 10-80yrs) Varones = feminas Embarazadas -1 Hospitalizaciones 3 Guillain Barre 1 Co- infecciones con influenza 1 Pruebas Trioplex en Laboratorio de Salud Publica

26. Preguntas ????????