Arizona Physician

Arizona Physician

Zika Virus, Where are We Now?

By Bob England, MD MPH
Director, Maricopa County Department of Public Health

What we know about Zika will change by the time you read this. That’s a key to dealing with this – don’t print out guidelines. They’ll be out-of-date by the time you need them. Look them up online instead.
In November, the World Health Organization declared the end of the “Public Health Emergency of International Concern” for Zika virus. I heard it on the radio myself… “WHO says Zika emergency is over.” So we can all stop worrying, right?
Wrong.
All that WHO was doing was making a technical change – switching the status from emergency to ongoing “significant enduring public health challenge.” What they were saying is that it’s here to stay.
But this is emblematic of communication problems with Zika virus – we’ve really messed up the messaging… with heartbreaking consequences. This is a much bigger problem than many people realize, and much worse than even I originally thought it would be.
Initially, I thought, “OK, some fraction of infants born to moms infected during pregnancy will be microcephalic –we’ll have to see what that fraction is.” But it has become much more than that. All sorts of neurologic deficits that present later are coming to light. Infections that occurred late in pregnancy have been shown to result in normal head size at birth, yet “late stage microcephaly” occurs as the brain does not continue to grow normally as the child ages.
The latest report from the CDC that I’ve seen reported on 13 infants born with congenital Zika infection but without microcephaly. All 13 showed malformations of cortical development and developed microcephaly after birth. Dysphagia, seizure disorders, visual disorders, hearing loss… all have been found so far, and no doubt other developmental and neurologic disorders are yet to be found as these children age.
Given the number of pregnancies in Zika endemic areas, and the developing economies involved with a limited capacity to afford extensive care for these children, the effect of this disaster will be felt for generations. And we are not immune to this here.
What you need to know right now
Pregnant women, women who may become pregnant, or their sexual partners should NOT travel to areas with Zika virus transmission. Do you know where these are? (Here’s the website to find out https://www.cdc.gov/zika/geo/active-countries.html ). They include our closest neighbor – right on our doorstep. There have been not one, but two clusters of local transmission of Zika in the state of Sonora, Mexico. So Mexico, including our neighbor immediately to the south, including border towns and areas, are considered to be areas with Zika virus transmission.
Tens of thousands of our residents cross our border to the south daily. Thousands are women who may become pregnant. Hundreds are pregnant at the time. Every single one of them is now considered at risk for Zika. All of them would qualify as priorities for testing for Zika infection. Yet none of them should be in that position.
Tell your female patients who are or may become pregnant not to travel to Mexico. Even to Nogales, Sonora, or other points south.
When Spring Break comes, tell all those young people not to go to Rocky Point. This is a big deal. Children will be born who will require care for a lifetime.
These are the current recommendations, as of the time of this writing:
1. Zika primarily spreads through:

a. infected mosquitos,
b. having sex, (even if the person does not have symptoms ) for up to 6 months after infection/exposure.
2. Zika’s best prevention strategies include:
a. Avoid unnecessary travel to areas with Zika virus transmission, refer to CDC’s map of affected countries with local spread of Zika at:
https://www.cdc.gov/zika/geo/active-countries.html
b. Avoid mosquito bites by using DEET-containing insect repellent, staying inside with closed screened doors and windows, wearing long shirts and/or pants.
c. Avoid unprotected sex within 6 months of travel to an area with Zika virus transmission and for the duration of the pregnancy if pregnant. The Zika virus has been found to persist in semen up to 188 days after symptom onset.
3. If a patient has returned from travel to area(s) with Zika virus transmission and is of child bearing age or has symptoms:
a. Obtain a thorough travel history including specific location(s) and date(s).
b. Determine if the patient was exposed to Zika using website above or calling public health (602-506-6767, Mon – Fri, 8AM-5PM; After-hours at 602-747-7111).
c. Educate regarding Zika symptoms including: 80% are asymptomatic; 20% have mild symptoms: rash, fever, joint/muscle pain, red eyes, and/or headache for < 1 week.
d. Everyone who has travelled to an area with Zika virus transmission should avoid mosquitoes for a minimum of 1-2 weeks after return from travel.
e. All pregnant women and symptomatic men/non-pregnant women returning from an area with Zika virus transmission are eligible for testing at the Arizona State Public Health Lab. Maricopa County Department of Public Health (MCDPH) will assist with risk assessment, testing coordination and counseling for interpretation of results.
Contact MCDPH Epidemiology at 602-506-6767, Mon – Fri, 8AM-5PM; After-hours at 602-747-7111 for assistance. Testing guidelines include:
i. Zika specimen testing is specific to timing of exposure after symptom onset and pregnancy status. For assistance with which test to order and which specimens to collect, call MCDPH or visit: http://www.azdhs.gov/documents/preparedness/epidemiology-disease-control/mosquito-borne/zika/zika-healthcare-provider-algorithms.pdf
ii. Specimen testing will be prioritized by the following: 1. Pregnant women with travel to an area with Zika virus transmission; 2. Symptomatic men and non-pregnant women with travel to an area with Zika virus transmission; 3. Individuals with travel to an area with Zika virus transmission and public health reason to test will be assessed on a case by case basis.
iii. Of note, those strongly suspected by clinician to have locally transmitted Zika infection with generalized rash plus two other symptoms (fever, joint pain and/or conjunctivitis) will also be prioritized for testing by public health.
4. Guidance for management of pregnant women who have been exposed to Zika virus can be found at: https://www.cdc.gov/zika/pregnancy/index.html
MCDPH offers updated Zika factsheets in English & Spanish to help with Zika awareness at: http://www.maricopa.gov/publichealth/Diseases/mosquito/

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