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![Preventing disease, promoting and protecting health
ZIKV: - Potential Neurological Sequelae
• Surveillance for potential Neurological Sequelae of ZIKV
– Monitoring Microcephaly
• Member States encouraged to strengthen or develop developmental anomaly registries
• Standardised criteria are needed.
– Proportionality criterion - Head circ = [((length/2)+10)±2] is useful as an initial flag
» See table on following slide
– Need for consultation with Specialist Stakeholders – Virtual meeting?
– Pilot database under construction for use in country and for data submission to CARPHA
– GBS Surveillance
• Standardised case definition needs to be employed for ascertainment
– Use and expansion of AFP system?
– Development of New reporting channel?
• There is need to prepare health systems to deal with potential surges of GBS
• CARPHA is refining tools to facilitate reporting and collation of data on both GBS and Microcephaly in Member
States](https://image.slidesharecdn.com/zikavirussurveillanceandreportingjoystjohn-carpha-160524081158/75/Zika-Virus-Surveillance-and-Reporting-in-the-Caribbean-26-2048.jpg)
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Zika Virus Surveillance and Reporting in the Caribbean
- 1. Preventing disease Promoting andprotecting health
- 2. Preventing disease, promotingand protecting health Zika Virus (ZIKV) Surveillance and Reporting Dr. Joy St. John Director Surveillance, Disease-Prevention and Control Division Caribbean Public Health Agency (CARPHA)
- 3. Preventing disease, promotingand protecting health Outline • Zika Virus (ZIKV) – Global Movement of ZIKV – ZIKV - Case Definition – The Caribbean Situation – ZIKV Testing Guidelines – Feedback on Testing to date – Surveillance for Neurological Sequelae • Microcephaly • Guillain Barre Syndrome – The pregnancy question
- 4. Preventing disease, promotingand protecting health GLOBAL MOVEMENT OF ZIKV A History
- 5. Preventing disease, promotingand protecting health 194 7 Discovered in Uganda 1947
- 6. Preventing disease, promotingand protecting health 194 8 Expansion other countries in Africa 1947-1948
- 7. Preventing disease, promotingand protecting health 197 7 Pakistan, Malaysia, Indonesia 1977-1978
- 8. Preventing disease, promotingand protecting health 197 8 Pakistan, Malaysia, Indonesia 1977-1978
- 9. Preventing disease, promotingand protecting health 200 7 Yap Island (Micronesia) and Guam, 2007 200 7
- 10. Preventing disease, promotingand protecting health 201 3 Tahiti, French Polynesia, 2013
- 11. Preventing disease, promotingand protecting health 201 4 New Caledonia (FR) and Cook Islands, 2014Easter Island (CHILE), 2014
- 12. Preventing disease, promotingand protecting health 201 5 Brazil, May 2015
- 13. Preventing disease, promotingand protecting health 201 6 Active transmission in the Americas 2016 (and other areas worldwide in previous 15 months, ECDC)
- 14. Preventing disease, promotingand protecting health Case Definition • The working case definition for Zika, is: • Rash or elevated body temperature (> 37.2 °C) with one or more of the following symptoms, not explained by other medical conditions • Arthralgia or myalgia (joint or muscle pain) • Non-purulent conjunctivitis or conjunctival hyperemia (reddened eyes, without mucous/discharge) • Headache or malaise AND • History of travel to a region with reported transmission (see following slide) – NB – travel history becomes less essential, the further ZIKV spreads through the region
- 15. Preventing disease, promotingand protecting health REGIONAL SITUATION
- 16. Preventing disease, promotingand protecting health Regional Territories With Confirmed local ZIKV cases CARPHA Member States • Aruba • Barbados • Bonaire • Curaçao • Guyana • Haiti • Jamaica • Sint Maarten • St. Vincent and the Grenadines • Suriname • Trinidad and Tobago Non-CMS Caribbean Islands • The Dominican Republic • Guadeloupe • Martinique • Puerto Rico, a US territory • Saint Martin (French) • U.S. Virgin Islands Level 2 Travel Notices (Practice Enhanced Precautions) have been posted to the CDC Website for each country *except USA
- 17. Preventing disease, promotingand protecting health Regional Territories With Confirmed local ZIKV cases • Bolivia • Brazil • Colombia • Ecuador • French Guiana • Paraguay • Venezuela Level 2 Travel Notices (Practice Enhanced Precautions) have been posted to the CDC Website for each country *except USA North American Territories Central America • Costa Rica • El Salvador • Guatemala • Honduras • Nicaragua • Panama South American Territories • Mexico • USA • *Sexual transmission (~15 cases)
- 18. Preventing disease, promotingand protecting health
- 19. Preventing disease, promotingand protecting health ZIKV TESTING AT CARPHA
- 20. Preventing disease, promotingand protecting health ZIKV Testing at CARPHA • If suspected cases with compatible clinical and epidemiological features are found in any CMS, CARPHA can provide diagnostic confirmation. • ZIKV can only be confirmed by PCR in our Dengue-endemic region – Extensive cross-reactivity between DENV IgM and ZIKV IgM makes serology uninterpretable in our Member States • Viraemia is highest within first 3 days of onset of symptoms and falls to undetectable levels after day 5 • Samples should therefore be taken from suspect cases between day 1 (day of onset) and day 5 and submitted to the local Public Health Lab for referral to CARPHA – Lab request forms should be appropriately filled out • Samples are subjected to an algorithm to rule out other prevalent arboviruses • Turn-around time ~ 5 (working) days
- 21. Preventing disease, promotingand protecting health Summary of results from Arboviral Algorithm (to Mid-February) 34 12 166 15 100 0 120 0 147 13 112 6 0 20 40 60 80 100 120 140 160 180 Tested Positive Tested Positive Jan Feb Results from Algorithm for PCR Testing for DENV CHIKV ZIKV DENV CHIKV ZIKV
- 22. Preventing disease, promotingand protecting health Dengue PCR breakdown Den I 17% Den II 8% Den III 33% Den IV 42% January Dengue PCR Den III 53% Den IV 47% February Dengue PCR
- 23. Preventing disease, promotingand protecting health Feedback from Laboratory • Need to reinforce completion of lab request forms – but vast improvements noted over previous outbreaks • Volume of requests affects turnaround time – Large numbers of samples sent at height of outbreak investigation needs to be reviewed. More judicious filtering needed in some instances • Testing window starts counting from day of onset as day 1 – (e.g. if fever or rash started on a Saturday, that would be is day 1 and the last day on which a sample could be taken would be the following Wednesday)
- 24. Preventing disease, promotingand protecting health MONITORING POTENTIAL NEUROLOGICAL SEQUELAE
- 25. Preventing disease, promotingand protecting health The Cause for Concern • In Late 2015 Brazil announced an unusual increase in Microcephaly cases in areas hard-hit by ZIKV • Initially > 3500 cases of microcephaly were identified, raising the incidence rate by a factor of ~ 20 • Subsequent review of the data revealed – >3000 cases were misclassified and discarded leaving ~ 500+ Microcephaly cases – Baseline data on Microcephaly may have been under-ascertained initially – Even the more modest increase is a cause for precautionary measures, however and WHO declared the phenomenon a PHEIC in February • There has also been a noted increase in Guillain Barre Syndrome in other States affected by ZIKV
- 26. Preventing disease, promotingand protecting health ZIKV: - Potential Neurological Sequelae • Surveillance for potential Neurological Sequelae of ZIKV – Monitoring Microcephaly • Member States encouraged to strengthen or develop developmental anomaly registries • Standardised criteria are needed. – Proportionality criterion - Head circ = [((length/2)+10)±2] is useful as an initial flag » See table on following slide – Need for consultation with Specialist Stakeholders – Virtual meeting? – Pilot database under construction for use in country and for data submission to CARPHA – GBS Surveillance • Standardised case definition needs to be employed for ascertainment – Use and expansion of AFP system? – Development of New reporting channel? • There is need to prepare health systems to deal with potential surges of GBS • CARPHA is refining tools to facilitate reporting and collation of data on both GBS and Microcephaly in Member States
- 27. Preventing disease, promotingand protecting health Sample Table – Head circ. flagged according to proportionality criteria Case Head Circ (cm) Length (cm) Lower Proportionalit y Criterion Upper Proportionalit y Criterion Weight (kg) Head Circ Centile Height Centile Weight Centile Actual 1 31.75 48.3 32.15 36.15 2.83<3 15 15 Actual 2 35 51 33.5 37.5 3.21 85 85 50 Actual 3 35.5 53 34.5 38.5 3.36 8585-97 50 Actual 4 34.5 51 33.5 37.5 3.3150-85 85 50 Actual 5 35 57.5 36.75 40.75 3.84 85>97 85 Fictional 1 37.5 50 33 37 Microcephaly Normal Head Size Macrocephaly NB Head circumference is also generally proportionate to other foetal measurements in terms of percentiles. Comparisons along these lines can also be made
- 28. Preventing disease, promotingand protecting health Photo credit: Image provided by mother of newborn (Rio de Janeiro, Brazil), with authorization for dissemination exclusively among public health workers. First reports in Brazil: Unusual increase of newborns with microcephaly
- 29. Preventing disease, promotingand protecting health AUTHORIZED PHOTOS OF CHILDREN WITH MICROCEPHALY. METROPOLITAN REGION OF RECIFE, 01/08 THROUGH 31/10/2015. Microcephaly cases
- 30. Preventing disease, promotingand protecting health CARPHA’s Advice to Pregnant Women • CARPHA recommends that women of childbearing age living in ZIKA affected take all preventive measures to avoid being bitten by mosquitoes, which in addition to Zika can also transmit diseases such as dengue and chikungunya. • Women who believe they have been exposed to Zika virus should consult with their healthcare provider for close monitoring of their pregnancy.
- 31. Preventing disease, promotingand protecting health Zika and Pregnancy • Association between ZIKV infection and congenital anomalies including Microcephaly is still under investigation • Precautionary principle is being applied: – WHO PHEIC – Close follow-up of pregnant women who manifest symptoms of ZIKA • Questions on ethics of active screening in pregnancy do need consideration – What actions will be considered after a positive diagnosis of ZIKV? – What actions will be considered if constrained brain growth is discovered? – What actions are permissible within our legal frameworks?
- 32. Preventing disease, promotingand protecting health Preventive measures Personal preventive measures: • The best way to prevent Zika is to avoid being bitten by mosquitoes. CARPHA advises that you take proper precautions to prevent being bitten: – Use insect repellants containing DEET (>10%), picaridin, oil of lemon eucalyptus or IR3535 on exposed skin. • Re-apply in accordance with instructions – Wear long-sleeved shirts and long pants. – Use air conditioning or have windows/doors securely closed or screened when indoors. – Sleep under mosquito nets. Environmental Preventive Measures • Identify and eliminate breeding sites in and around homes • Cooperate with activities of local Vector Control Agencies
- 33. Preventing disease, promotingand protecting health Conclusions • Zika is likely to continue its spread through the Caribbean region • Vigilance is advised, to detect index cases and heighten vector control activities • All persons are advised to employ both environmental and personal strategies to reduce the risk of being bitten • Pregnant women are advised to take special care to avoid mosquito bites and to report any symptoms suggestive of ZIKV to their obstetrician/doctors • Surveillance for neurological sequelae needs to be established • Preparations for surges in GBS in member states are needed