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Zika medical facts


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Dr. Devon Davis presents Zika facts.

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Zika medical facts

  1. 1. ZIKA: WHAT YOU NEED TO KNOW Devon L. Davis, MD Director, Medical Operations Elite Medical Group
  2. 2. PURPOSE OF PRESENTATION SLIDE 2 • Explore the virus and emerging problems worldwide • Review symptoms, diagnosis and treatment • Focus on special cases • Target prevention strategies • Discuss global implications
  3. 3. Global Rescue’s Boston Operations Center GLOBAL RESCUE Founded in 2004, U.S. based integrated provider of: • Medical Services • Security Services • Field Rescue Services • Intelligence, Information & Mobile Communication Services • Crisis Planning & Response Services Operations Centers located in: • Massachusetts • New Hampshire • Pakistan • Thailand SLIDE 3
  4. 4. DEVON L. DAVIS, MD Director – Medical Operations, Elite Medical Group Oversees worldwide medical operations for Elite Medical Group. Board-certified Emergency Physician with 19 years of clinical practice. • Extensive experience as medical director of multiple emergency medical service agencies with emphasis on mass casualty events. • Senior Doctor for Norwegian Cruise Line. Education • Residency-University of Pittsburgh Affiliated Residency in Emergency Medicine • MD-Vanderbilt University School of Medicine • BA-Dartmouth College SLIDE 4
  5. 5. INTRODUCTION ‘Zika’ has become a household word in the past 6-12 months due to: • Its rapid spread in multiple countries • Its impact on international travel • The significant health implications for adults, children, and particularly unborn fetuses SLIDE 5
  6. 6. Single-stranded RNA Arbovirus- Flavivirus: • 1947: Discovered in the Ugandan Zika Forest in rhesus monkey with a fever • 1952: First human diagnosis • 1953-2006: Occasional outbreaks; likely many more cases than reported • 2007: Yap State, Federated States of Micronesia; • 2013-2014: French Polynesia WHAT IS ZIKA? SLIDE 6
  7. 7. • May 2015: 1st confirmed case in Brazil • February 2016: Zika declared a PHEIC (Public Health Emergency of International Concern) by World Health Organization WHAT IS ZIKA? (CONT.) PHEIC “An extraordinary event which is determined to constitute a public health risk to other states through the international spread of disease and to potentially require a coordinated international response.” SLIDE 7
  8. 8. Bites of Aedes aegypti or Aedes albopictus mosquitoes, which: • Also spread Dengue and Chikungunya • Live near people • Bite mostly in the daytime — dawn to dusk • Often feed on multiple people for one blood meal • Lay eggs in standing water (up to 200 eggs/3 days) • “Cockroach” of the mosquito — very hardy • Eggs can remain dry up to 1 year then hatch with water contact TRANSMISSION SLIDE 8
  9. 9. Zika can also be passed from a mother to unborn fetus • Now linked to severe birth defects such as microcephaly Sexual contact: • Virus persists longer in semen than in blood • Can be passed from male to his partner • Currently no evidence yet that can be passed from female to partner Blood transfusion Laboratory exposure — route is unclear TRANSMISSION (CONT.) SLIDE 9
  10. 10. WHERE IS ZIKA FOUND? • <2015: Mostly in Africa, Southeast Asia, Pacific Islands • May 2015: Brazil • 2015-2016: Many countries, especially the Americas SLIDE 10
  12. 12. Endemic countries have had Zika in the past and have occasional new cases: • Provides immunity to the local inhabitants • Reduced risk to travelers Epidemic countries have current outbreaks and have not had Zika in the past: • Little immunity for locals • Higher risk to travelers ENDEMIC VS. EPIDEMIC SLIDE 12
  13. 13. CDC Data as of July 6, 2016 U.S.: • No locally-acquired mosquito-transmitted cases in US • 1,132 travel-acquired cases • 1 lab-acquired case • 14 sexually-transmitted cases • 5 cases of subsequent Guillain-Barré Syndrome • 1 death (?) US territories: • 2,526 locally-acquired • 8 travel-associated • 12 cases of GBS • Sexually transmitted not reported in mosquito-borne illness areas • 1 death (thrombocytopenia) US DATA SLIDE 13
  14. 14. • Fever, joint/muscle pain, rash, conjunctivitis, headache • Symptoms usually last a few days to a week—mostly mild—”flu” • Incubation period not well known • Many asymptomatic (up to 80%) or mild disease • Few hospitalizations/deaths • Infection likely gives future immunity • Similar to other mosquito-borne diseases like Dengue and Chikungunya ZIKA PRESENTATION Image: SLIDE 14
  15. 15. Zika can be a clinical diagnosis but can be tested in both blood and urine by RT-PCR Ab testing less reliable due to cross-reactivity with other viruses Disease typically self-limiting : • Oral fluids, rest, and anti-pyretics like Tylenol usually sufficient • Hospitalization rarely needed • Avoid NSAIDs/Aspirin until confirmed that not Dengue (bleeding complications with Dengue) • Avoid mosquito bites during first week of illness —can spread to others via mosquitos No vaccine available DIAGNOSIS AND TREATMENT SLIDE 15
  16. 16. • Dengue • Chikungunya • Yellow Fever • Malaria • West Nile Virus • Eastern/Western Equine Encephalitis • St. Louis Encephalitis • LaCrosse Encephalitis • Zika MOSQUITO-BORNE ILLNESSES SLIDE 16
  17. 17. PROBLEMS WITH ZIKA Majority of cases of Zika infection resolve without incident Several instances with far-reaching negative implications: • Pregnancy • Sexual transmission • Post-viral sequelae SLIDE 17
  18. 18. • Certain birth defects in fetuses or infants born to mothers infected with Zika • CDC and WHO cautions to women who live in Zika-infected areas or who are traveling to Zika prevalent areas • Cautions also to couples about protected intercourse or abstention • Breastfeeding still recommended (currently) ZIKA AND PREGNANCY Image: SLIDE 18
  19. 19. • Since May 2015 outbreak in Brazil, significant increase in babies born with microcephaly (small head) & other defects • Rare: 6/10,000 births in US • Causes: genetic, infection (rubella, CMV), severe malnutrition, exposures to ETOH/chemicals, poor blood supply to brain in utero • Increase in instances of microcephaly in babies with mothers positive for Zika has caused great concern worldwide MICROCEPHALY Image: SLIDE 19
  20. 20. • A spectrum of severity from mild to severe • Seizures, vision/hearing disorders, movement/balance problems, developmental and intellectual delay, difficulty swallowing • Can be noted on ultrasound but not very sensitive • After birth head circumference remains <3rd percentile • No cure or treatment • Fetal brain disruption sequence-collapse of skull after destruction of brain tissue • Congenital Zika Syndrome: severe microcephaly, other brain & eye abnormalities, redundant scalp skin, arthrogryposis, clubfoot MICROCEPHALY (CONT.) SLIDE 20
  21. 21. SLIDE 21
  22. 22. Case report from New England Journal of Medicine – March 2016: • 25 yo healthy female from Slovenia, a volunteer in Brazil since 2013 • Pregnant in Feb. 2015 febrile illness with itchy rash at 13 weeks • No testing for Zika done at the time • U/S @ 14 and 20 weeks unremarkable • Returned to Europe – U/S @ 29 weeks showed fetal defects • Presented to Dept. of Perinatology in Ljubljana, Slovenia • Pregnancy terminated @32 weeks – severe microcephaly and other significant defects • Pathology indicated Zika virus in brain tissue MICROCEPHALY (CONT.) SLIDE 22
  23. 23. • Search for causality for the microcephalic babies in Brazil • Reviewed the data using methods for determining teratogenicity • 2013-14 outbreak in French Polynesia noted similar increase in microcephalic infants • Defects consistent with infection during 1st or 2nd trimester • Conclusion: +causal relationship between a Zika-infected mother and microcephaly, other birth defects NEW ENGLAND JOURNAL OF MEDICINE - MAY 2016 SLIDE 23
  24. 24. RECOMMENDATIONS FOR PREGNANCY Virus remains in semen longer than in blood; exact duration not clear Pregnant women who live in or have traveled to Zika areas: • Use condoms or abstain from intercourse during the pregnancy; • Prevent further mosquito bites SLIDE 24
  25. 25. Testing: • Pregnant women w/potential exposure should be tested if either she or partner develops symptoms • Pregnant women who have visited a Zika area should be tested and have ultrasounds during pregnancy, even if asymptomatic • Not as useful to test male partner—false negatives; virus may still be in semen but not in blood; Ab level often not detectable • No attempt at pregnancy recommended for 8 weeks after leaving Zika-prevalent country RECOMMENDATIONS FOR PREGNANCY (CONT.) SLIDE 25
  26. 26. SEXUAL TRANSMISSION Zika virus can be passed through sexual contact First documented case 2008 Via oral, vaginal or anal intercourse • Known that can pass from male to his partner • Unclear if female can spread virus to her partner —currently no known cases SLIDE 26
  27. 27. • Virus can be transmitted before or after symptoms appear or even without symptoms • Virus found in blood, semen, urine, saliva, breast milk but not vaginal swabs • Virus persists longer in semen than in blood—isolated from semen weeks after illness onset when blood negative • Condoms or abstinence provide best protection • Not clear if birth defects same if disease acquired through sexual contact vs. mosquito bite SEXUAL TRANSMISSION (CONT.) Image: SLIDE 27
  28. 28. Travelers to Zika areas: • Male partner with symptoms: condoms/no sex for 6 months • Male partner without symptoms: condoms/no sex for 8 weeks after return Living in Zika areas: • Male partner with symptoms: condoms/no sex for 6 months • Male partner without symptoms: consider precautions while Zika is in the area SEXUAL TRANSMISSION (CONT.) Image: SLIDE 28
  29. 29. • Increase in cases of Guillain-Barré Syndrome noted in patients s/p Zika illness • GBS is an autoimmune disease that attacks the peripheral nervous system • Causes an ascending flaccid paralysis and sensory loss • More common in adults than children • Most recover-some serious cases have long- term complications, can be deadly • Often triggered by viral or bacterial infection or other stressors (surgery, trauma, or rarely immunizations) • Diagnosed by loss of DTR’s, lumbar puncture • No cure-mostly supportive treatment (IV immunoglobulin and plasmapheresis may be helpful) GUILLAIN-BARRÉ SYNDROME Image: SLIDE 29
  30. 30. NEJM April 2016 article: • Possible mutation that gives the current strain increased virulence and ease of transmission • Don’t see incidence of microcephaly and Guillain-Barré • Syndrome in endemic areas of Zika—likely because most children have contracted the disease at some point. Children less likely to have GBS. They are likely immune by the time old enough for pregnancy. GUILLAIN-BARRÉ SYNDROME (CONT.) SLIDE 30
  31. 31. DR. MARIA ADELAIDA VELEZ GARCIA —OB/GYN IN CALI, COLOMBIA • 2500 patients/year (1,800 OB, consults on additional 1,200) • December 2015 – June 2016: 21 pregnant patients + for Zika • 10 fetuses with microcephaly or other defects, including intracranial calcifications, poor brain development – 5 were aborted • Study from Brazil had a birth defect rate of about 29% Image: SLIDE 31
  32. 32. “Preliminary surveillance data in Colombia suggests that maternal infection with the Zika virus during the third trimester of pregnancy is not linked to structural abnormalities in the fetus. However, the monitoring of the effect of ZVD on pregnant women in Colombia is ongoing.” JUNE 2016 NEJM: COLOMBIA SLIDE 32
  33. 33. Letter to the Editor: Authors’ research has shown an increase in requests for abortion medications through the Internet in Latin American countries that either restrict or prohibit abortion. JUNE 2016 NEJM SLIDE 33
  34. 34. • No vaccine • Avoiding bites by the Aedes mosquito is the best way to prevent infection with Zika virus • Use insect repellents that contain DEET, picardin, IR3535 or oil of lemon & eucalyptus or para-menthane-diol products • Sunscreen first • Wear long sleeves, long pants and/or permethrin-treated clothing • Use air conditioning and screens in windows or mosquito netting • Get rid of standing water • Vector control—eggs and adult mosquitos PREVENTION Image: SLIDE 34
  36. 36. APRIL 14, 2016 SLIDE 36 RIO OLYMPIC GAMES
  37. 37. 238-physician letter to the WHO (June 2016) Multiple athletes dropping out International Journal of Infectious Diseases (Feb. 2016) —preparedness for mass gatherings: • Vector control by Brazilian government • Increased awareness • Improved testing capability • Facilities for treatment of sequelae/complications • Education of athletes and visitors in prevention Winter season in Brazil (fewer mosquitoes) July 2016, The Lancet: Zika risk for Rio games 15x LESS than risk of Dengue during 2014 World Cup in Brazil RIO OLYMPICS SLIDE 37
  38. 38. CDC recommendations for travelers: • Pregnant women—not to any area with Zika • If must, should follow guidelines for mosquito bite prevention • Get good prenatal care including testing with or without symptoms Safe sex for all travelers Use preventive measures After return home: • Avoid mosquito bites for several weeks • Safe sex for 8 weeks (6 months if male has symptoms; male partners of pregnant women—condom use or abstention until pregnancy over) INTERNATIONAL TRAVEL SLIDE 38
  39. 39. SPREAD OF ZIKA Current outbreak spread quickly to a multitude of countries Asian strain (French Polynesia, Cambodia, Yap) Spread by mosquitoes: • Aedes aegypti located in warmer zones • Aedes albopictus can survive cooler temps Image: figure 3 SLIDE 39
  40. 40. Zika mosquitoes do not like to live at altitudes greater than 6500ft (2000m) above sea level Some feel that an outbreak in the US is unlikely: • Even warmer states get cool temps in the winter months • Advanced countries have increased use of air conditioning and window screens • Proactive vector control including aerial spraying for mosquitos Puerto Rico and aerial spraying Travelers returning from Zika areas must avoid mosquito bites Concerns for worldwide spread still exist… SPREAD OF ZIKA (CONT.) SLIDE 40
  41. 41. US AREAS OF RISK Image: figure 3 SLIDE 41
  42. 42. POLITICS, RELIGION AND THE MEDIA • May 2016 and July 2016 - Director of CDC makes pleas for federal funding for Zika • US Congress controversy • MDs’ letter to WHO ran on CNN + other news stations • Started with 100 signatures • Now nearly 240 • Pop media and Internet sites postulate every theory from Olympics problems to population control/terrorism • Pope Francis has even weighed in Image: figure 3 SLIDE 42
  43. 43. Zika is an international public health problem Spread must be controlled Need research into: • Vaccine • Rapid diagnosis • Treatment • Prevention • Zika as cause of birth defects and Guillain-Barré Syndrome CONCLUSIONS Image: SLIDE 43
  44. 44. 15.“El Salvador confirms second case of Zika-linked microcephaly,” Fox News, July 11, 2016. 16.“El Salvador confirms second case of Zika-linked microcephaly,” Fox News, July 11, 2016. 17.“CDC Head Tom Frieden Delivers Emotional Plea for Zika Funding,” Huffington Post, May 26, 2016. 18.“Utah resident is first Zika-related death in continental US,” CNN, July 8, 2016. 19.“Utah woman is 1st confirmed Zika-related death in continental US,”, July 9, 2016. 20.“Officials confirm Zika-related death in Utah was a man,” Washington Post, July 11, 2016. 21.“On Zika, Obama warns congressional inaction could cause ‘tragedies that can last a lifetime,’” Washington Post, July 1, 2016. 22.“White House threatens to veto $1.1 GOP Zika bill, “ Fox News, June 23, 2016. 23.“Amid Zika Crisis, House GOP Proposes Eliminating Birth Control Program,” Huffington Post, July 6, 2016. 24.“Brazil says the is ‘almost zero’ risk of Zika during Olympics. Really?” Washington Post, July 6, 2016. 25.US Reports 279 Zika cases in pregnant women, Obama pushes Congress on funds,” The Himalayan, May 21, 2016. 26.“Climate Change Bites,”, December 31, 2015 27.“Pope Francis suggests contraception could be permissible in Zika fight,” Washington Post, February 18, 2016. 28.“the Real Surprise in Pope Francis’ Zika virus remarks,”, February 19, 2016. 29.“US Centers for Disease Control and Prevention and Environmental Protection Agency Urge Commonwealth of Puerto Rico to Consider Aerial Spraying as Part of Integrated Mosquito Control to Reduce Zika-Associated Birth Defects,” CDC Media Statement, July 6, 2016. 30.“US Reports First Zika Virus Death in Puerto Rico,”, April 29, 2016. 31.“Pope Francis: Abortion is evil, not the solution to Zika virus,”, February 18, 2016 . REFERENCES 1.Pacheco, Oscar et al. Zika Virus Disease in Colombia— Preliminary Report. N Engl J Med Online. June 15, 2016. 2.Petersen, Lyle R. et al. Zika Virus. N Engl J Med 2016; 374: 1552-1563. 3.Massad, Eduardo et al. Is Zika a substantial risk for visitors to the Rio de Janeiro Olympic Games? The Lancet 2016; Vol. 388, No. 10039, p.25. 4.Mlakar, Jernej et al. Zika Virus Associated with Microcephaly . N Engl J Med 2016; 374:951-958. 5.Rasmussen, Sonja A. et al. Zika Virus and Birth Defects— Reviewing the Evidence for Causality . N Engl J Med 2016; 374: 1981-1987. 6.Franca, Giovanny VA et al. Congenital Zika virus syndrome in Brazil: a case series of the first 1501 live births with complete investigation. The Lancet Online. June 29, 2016. 7.Letter to Editor. Requests for Abortion in Latin America Related to Concern about Zika Virus Exposure. N Engl J Med. June 22, 2016. 8.Petersen, Eskild et al. Unexpected and Rapid Spread of Zika Virus in the Americas-Implications for Public Health Preparedness for Mass Gatherings at the 2016 Brazil Olympic Games. International Journal of Infectious Diseases 2016; 44 : 11-15. 9.Musso, D. et al. Rapid Spread of Emerging Zika Virus in the Pacific Area. Clinical Microbiology and Infection 2014; Vol. 20, Issue 10: 595-596. 10.Besnard, M. et al. Evidence of Perinatal Transmission of Zika Virus, French Polynesia, December 2013 and February 2014 . Eurosurveillance 2014; Vol. 19, Issue 13. 11.CDC website: 12.WHO website: 13.Mosquito-Borne Diseases. American Mosquito Control Association. 14.“As New Olympians Celebrate Victory, Families Contemplate Safety,” New York Times, July 3, 2016. SLIDE 44
  45. 45. QUESTIONS? SLIDE 45