Dallas County Issues Zika Sexual Transmission Advisory

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http://www.dallascounty.org/department/hhs/documents/DCHHS_Zika_HealthAdvisory_20160202_final.pdf

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DALLAS COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES EPIDEMIOLOGY

Zachary Thompson Dr. Christopher Perkins Director Health Authority/Medical Director

2377 N. Stemmons Freeway Office: 214-819-2004 Dallas, Texas 75207  Fax: 214-819-1933

From: Jessica Smith, MPH, Senait Woldai, MPH Wendy Chung, MD, Chief Epidemiologist

To: Dallas County Medical Providers Date: February 2, 2016

HEALTH ADVISORY: Sexual Transmission of Zika Virus Dallas County Health and Human Services (DCHHS) has received confirmation from the Centers of Disease Control and Prevention (CDC) that Zika virus infection has been confirmed in two persons residing in Dallas County. One patient developed illness symptoms after returning from a country in South America with active Zika transmission. The second patient had not recently traveled outside of the U.S., but subsequently developed illness symptoms after sexual contact with the traveler. There was no risk to a developing fetus with these cases; both patients have recovered fully from their illnesses. Symptoms occur in 1 in 5 persons infected with Zika virus and include fever, conjunctivitis, rash, and/or arthralgia.1 The illness is typically mild and resolves within one week. However, Zika infection in pregnant women may be associated with congenital microcephaly and fetal losses. Guillain-Barre syndrome has also been reported in patients after suspected Zika infection. Zika virus is transmitted to persons primarily through the bite of an infected Aedes species mosquito.

Recent temperatures in our area were not conducive to Aedes mosquito activity, although such mosquitoes are usually present in our area during the warmer late-spring and summer months. Vector surveillance has also confirmed the absence of this species in vicinity BG mosquito traps at this time. Probable spread of the virus through sexual contact has been described in one prior case report. Maternal-fetal transmission of Zika virus has been documented in pregnancy and possible transfusion transmission events have also been reported.

Clinicians should consider Zika virus infection in patients (including pregnant women2 ) with 2 or more compatible symptoms (e.g., fever, rash, conjunctivitis or joint pain) within 2 weeks of travel to an area with autochthonous Zika virus transmission. 3 In addition, Zika infection should be considered in patients with compatible clinical syndrome but without travel history, who report recent unprotected sexual contact (within the previous 2 weeks) with a person with a compatible history of illness and history of travel. The current outbreak of Zika virus in the Americas is unprecedented in magnitude, and clinical guidance is anticipated to evolve as more information rapidly accrues.

At this time, all area clinicians should refer to most updated information available at (http://www.cdc.gov/zika/) and be aware of the following: Current DCHHS Testing Guidance: Currently, all PCR and serologic testing for Zika virus in Texas is being referred to CDC. The DCHHS laboratory is anticipated to gain capacity to conduct PCR testing for Zika virus beginning in midFebruary. To discuss testing, clinicians should contact the DCHHS Epidemiology division at 214-819-2004 or 214-677-7899 (on-call 24/7) and complete the required DCHHS Zika Virus Clinical Specimen Submission Form. 4 Instructions for specimen submission to DCHHS are available at: DCHHS Submission Instructions for Zika Virus Testing. 5

Patients MUST meet the following epidemiologic criteria BEFORE a specimen can be sent to DCHHS:

1. Any patient (including pregnant women2 ) with 2 or more symptoms compatible with Zika virus infection (e.g., fever, rash, joint pain, or conjunctivitis) within 2 weeks of travel to an area with Zika virus transmission. 3

2. Any patient with symptoms of Guillain-Barré syndrome (GBS) within 1 month of travel to an area with Zika virus transmission.

3. Infants born to women with positive or inconclusive test results for Zika infection.6

4. Infants with microcephaly or intracranial calcifications born to women who have traveled to an area with Zika virus transmission while pregnant.6

5. Patients with compatible illness who do not meet above testing criteria, but for whom there may be concern for alternate (e.g. sexual, non-perinatal) modes of transmission, 7 should be discussed with DCHHS Epidemiology division for case-by-case evaluation and determination of approval for testing. CDC recommends that diagnostic testing for dengue and chikungunya also be considered in patients with possible Zika virus infection who have traveled within the previous 2 weeks to an area with ongoing transmission.8 Testing for dengue and chikungunya is available from commercial laboratories.

Patient Counseling:

• All persons should take steps to avoid mosquito bites to prevent mosquito-borne diseases.

• Patients with suspected infection with Zika virus should be advised to avoid mosquito bites for 7 days following illness onset.

• Fever should be treated with acetaminophen; aspirin and other non-steroidal anti-inflammatory drugs should be avoided until dengue can be ruled out to reduce the risk of hemorrhage.

• Pregnant women should defer travel to areas with Zika virus transmission. For interim guidelines for pregnant women, providers should refer to most updated CDC and ACOG/SMFM websites.

• Although more specific guidance is expected to be available as additional information becomes known, given the current evidence for potential sexual transmission, persons who have traveled to areas with active Zika transmission may consider using condoms during sexual activity, particularly if their partner is pregnant. Public Health Notification: Healthcare providers in Dallas County who identify persons with possible infection with Zika virus are requested to report such cases to DCHHS by phone within 1 working day at (214) 819-2004. ____________________________________________________________________________________

1. CDC Health Advisory. Recognizing, Managing, and Reporting Zika Virus Infections in Travelers Returning from Central America, South America, the Caribbean, and Mexico (1/15/16): http://emergency.cdc.gov/han/han00385.asp

2. CDC. Interim Guidance for Pregnant Women During a Zika Virus Outbreak — United States, 2016 (1/19/2016): http://www.cdc.gov/mmwr/volumes/65/wr/mm6502e1.htm

3. CDC. Areas with Zika Transmission (2/1/16): http://www.cdc.gov/zika/geo/index.html

4. DCHHS Zika Virus Specimen Submission Form (2/1/16): http://www.dallascounty.org/department/hhs/documents/DCHHS_Zika_SubmissionForm_020116.pdf

5. DCHHS Submission Instructions for Zika Virus Testing (2/1/16): http://www.dallascounty.org/department/hhs/documents/DCHHS_Zika_SubmissionGuidance_020116_Interim.pdf

6. CDC. Interim Guidelines for the Evaluation and Testing of Infants with Possible Congenital Zika Virus Infection — United States, 2016 (1/26/16): http://www.cdc.gov/mmwr/volumes/65/wr/mm6503e3.htm

7. CDC COCA Call. Zika Virus — What Clinicians Need to Know (1/26/16): http://emergency.cdc.gov/coca/calls/2016/callinfo_012616.asp

8. CDC Memorandum. Updated diagnostic testing for Zika, chikungunya, and dengue

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DCHHS Provides Update on 
Zika Virus Cases

 

DALLAS (Feb. 4, 2016) – Dallas County Health and Human Services (DCHHS) has completed the initial public health investigation on the two Zika cases reported Feb. 2. Both patients have recovered fully. As part of the public health follow-up, the patients have been advised to follow up with their physician. DCHHS conducted mosquito surveillance in the area of the patients’ residence and did not identify any mosquito/vector activity. See the DCHHS health advisory for more information.DCHHS does not have further updates on the two cases reported Feb. 2.

 

DCHHS is awaiting four Zika virus specimen results from the Centers for Disease Control and Prevention.

 

For information on Zika virus, go to the DCHHS website.

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Media Statement

 

For Immediate Release

Tuesday, February 23, 2016

                                                                         

Contact: CDC Media Relations

404-639-3286                                                 

 

 

CDC encourages following guidance to prevent sexual transmission of Zika virus

 

CDC has committed to sharing the latest information on Zika virus as it becomes available. On February 5, 2016, CDC published interim recommendations for protecting people against sexual transmission of Zika virus.  This guidance was issued after lab confirmation of the first case of Zika virus infection in a non-traveler in the continental United States, which was linked to sexual contact with an infected partner.

CDC and state public health departments are now investigating 14 new reports of possible sexual transmission of Zika virus, including several involving pregnant women. In two of the new suspected sexual transmission events, Zika virus infection has been confirmed in women whose only known risk factor was sexual contact with an ill male partner who had recently traveled to an area with local Zika virus transmission; testing for the male partners is still pending. For four additional suspected sexual transmission events, preliminary laboratory evidence (IgM antibody test) is available for the women, but confirmatory tests are pending. For eight other suspected events, the investigation is ongoing. In all events for which information is available, travelers were men and reported symptom onset was within 2 weeks before the non-traveling female partner’s symptoms began.  Like previously reported cases of sexual transmission, these cases involve possible transmission of the virus from men to their sex partners.  At this time, there is no evidence that women can transmit Zika virus to their sex partners; however, more research is needed to understand this issue.

Although sexual transmission of Zika virus infection is possible, mosquito bites remain the primary way that Zika virus is transmitted. Because there currently is no vaccine or treatment for Zika virus, the best way to avoid Zika virus infection is to prevent mosquito bites.

Because these new reports suggest sexual transmission may be a more likely means of transmission for Zika virus than previously considered, CDC issued a Health Advisory Notice (HAN) today to underscore the importance of adhering to the interim guidance published on February 5.

The CDC’s February 5 interim guidance includes:

Recommendations for pregnant women and men with pregnant sex partners who live in or have traveled to Zika-affected areas:

·         Pregnant women and their male sex partners should discuss the male partner’s potential exposures and history of Zika-like illness with the pregnant woman’s health care provider (http://www.cdc.gov/zika/symptoms/). Providers should consult CDC’s guidelines for evaluation and testing of pregnant women.

·         Men with a pregnant sex partner who reside in or have traveled to an area of active Zika virus transmission and their pregnant sex partners should use condoms the right way every time during sex (vaginal, anal, or oral) or abstain from sexual activity for the duration of the pregnancy. Using latex condoms the right way every time reduces the risk of sexual transmission of many infections, including those caused by other viruses.

Recommendations for non-pregnant women, and men with non-pregnant sex partners who live in or have traveled to Zika-affected areas:

·         Couples in which a man resides in or has traveled to an area of active Zika virus transmission who are concerned about sexual transmission of Zika virus may consider using condoms the right way every time during sex or abstaining from sexual activity.  

·         Couples may consider several factors when making this complex and personal decision to use condoms or not have sex:

o    Zika virus illness is usually mild. An estimated 4 out of 5 people infected never have symptoms; when symptoms occur they may last from several days to one week.

o    The risk of Zika infection depends on how long and how much a person has been exposed to infected mosquitoes, and the steps taken to prevent mosquito bites while in an affected area.

·         The science is not clear on how long the risk should be avoided. Research is now underway to answer this question as soon as possible. If you are trying to get pregnant, you may consider testing in discussion with your health care provider.

These investigations are preliminary, and CDC will continue to update its guidance as more information becomes available.  

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U.S. Department of Health and Human Services

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Update: Interim Guidelines for Prevention of Sexual Transmission of Zika Virus — United States, 2016

 

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This is an official

CDC HEALTH ADVISORY

Distributed via the CDC Health Alert Network
February 23, 2016, 14:15 EST (2:15 PM EST)
CDCHAN-00388

Summary: The Centers for Disease Control and Prevention (CDC) recently published recommendations for protecting people against sexual transmission of Zika virus (1). As stated in that report, information about possible sexual transmission of Zika virus was based on one published report of transmission from a man to a woman, one published report in which Zika virus was detected in semen of a man with hematospermia, and one case of possible sexual  transmission then under investigation in Texas. An additional case of Zika virus detected in semen in a man was reported after the CDC recommendations were published (2).  As of February 23, 2016, CDC and state public health departments are investigating 14 additional reports of possible sexual transmission of the virus, including several involving pregnant women. While additional investigations are being completed, CDC is issuing this HAN Advisory as a strong reminder to state, local, and US territorial public health departments, clinicians, and the public to be aware of and adhere to current recommendations for preventing sexual transmission of Zika virus, particularly for men with pregnant partners. These recommendations may change as more information becomes available.

 

Background

CDC is working with state, local, and US territorial public health departments, US Government agencies, and international partners in response to outbreaks of Zika virus disease (Zika) in multiple territories and countries in the Americas. Accumulating evidence links maternal Zika virus infection with congenital microcephaly, miscarriages, and other adverse fetal outcomes (3). In addition, there are reports of a possible association with Guillain-Barré syndrome (4). No vaccine or specific antiviral drug is currently available to prevent or treat Zika.

Zika virus is spread primarily by the bite of infected Aedes species mosquitoes (most commonly, Aedes aegypti). In areas where Zika virus transmission is ongoing, people should follow precautions to prevent mosquito bites (http://www.cdc.gov/zika/prevention/). Sexual transmission of Zika virus also can occur and is of particular concern during pregnancy. In early February 2016, the Dallas County Department of Health and Human Services announced an occurrence of sexually transmitted Zika infection (5). On February 5, 2016, following the confirmation of this Texas sexual transmission event, CDC published interim guidelines for preventing sexual transmission of Zika virus (1).

As of February 23, 2016, CDC and state public health departments are investigating 14 additional reports of possible sexual transmission of the virus, including several events involving possible transmission to pregnant women. In two of these new suspected sexual transmission events that have been investigated to date, Zika virus infection has been confirmed in women whose only known risk factor was sexual contact with an ill male partner who had recently travelled to an area with local Zika virus transmission; testing for the male partners is pending. For four additional suspected sexual transmission events, preliminary laboratory evidence (IgM antibody test) is available for the women, but confirmatory testing is still pending. For eight suspected events, the investigation is ongoing. In all events for which information is available, travelers reported symptom onset within 2 weeks prior to their non-traveling female partner’s symptom onset.

Because these reports suggest sexual transmission may be a more likely means of transmission for Zika virus than previously considered, CDC is issuing this HAN Advisory to underscore the importance of adhering to the interim guidance published on February 5 and outlined below. The recommendations, which apply to men who reside in or have traveled to areas with active Zika virus transmission (http://wwwnc.cdc.gov/travel/notices/) and their sex partners, will be revised as more information becomes available.

Recommendations for men and their pregnant partners

Men who reside in or have traveled to an area of active Zika virus transmission who have a pregnant partner should abstain from sexual activity or consistently and correctly use condoms during sex (i.e., vaginal intercourse, anal intercourse, or fellatio) for the duration of the pregnancy. Pregnant women should discuss their male partner’s potential exposures to mosquitoes and history of Zika-like illness (http://www.cdc.gov/zika/symptoms) with their health care provider; providers can consult CDC’s guidelines for evaluation and testing of pregnant women (6).

Recommendations for men and their nonpregnant sex partners

Men who reside in or have traveled to an area of active Zika virus transmission who are concerned about sexual transmission of Zika virus might consider abstaining from sexual activity or using condoms consistently and correctly during sex. Couples considering this personal decision should take several factors into account. Most infections are asymptomatic, and when illness does occur, it is usually mild with symptoms lasting from several days to a week; severe disease requiring hospitalization is uncommon. The risk for acquiring vector-borne Zika virus in areas of active transmission depends on the duration and extent of exposure to infected mosquitoes and the steps taken to prevent mosquito bites (http://www.cdc.gov/zika/prevention). After infection, Zika virus might persist in semen when it is no longer detectable in blood; studies to determine the duration of persistence in semen are not yet completed.

Accumulating evidence of sexual transmission suggests that exposure to Zika virus includes unprotected sexual contact with a symptomatic male partner who resides in or has traveled to an area of active Zika virus transmission. Zika virus testing is currently recommended to establish a diagnosis of infection in exposed persons with signs or symptoms consistent with Zika virus disease, and may be offered to asymptomatic pregnant women with possible exposure to Zika virus (6). However, interpretation of results is complex, and health care providers should contact their state, local, or territorial health department for assistance with arranging testing and interpreting results. At this time, testing of exposed, asymptomatic men for the purpose of assessing risk for sexual transmission is not recommended. Sexual transmission of Zika virus from infected women to their sex partners has not been documented, nor has transmission from persons who are asymptomatically infected.  Sexual transmission of many infections, including those caused by other viruses, is reduced by consistent and correct use of latex condoms.

As we learn more about the incidence and duration of seminal shedding from infected men and the utility and availability of testing in this context, recommendations to prevent sexual transmission of Zika virus will be updated.

References

1. Oster AM, Brooks JT, Stryker JE, et al. Interim Guidelines for prevention of sexual transmission of Zika virus — United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:120–121. http://www.cdc.gov/mmwr/volumes/65/wr/mm6505e1.htm
2. Atkinson B, Hearn P, Afrough B, et al. Detection of Zika virus in semen [letter]. Emerg Infect Dis. 2016 May [cited February 22, 2016].http://dx.doi.org/10.3201/eid2205.160107
3. Martines RB, Bhatnagar J, Keating MK, et al. Evidence of Zika virus infection in brain and placental tissues from two congenitally infected newborns and two fetal losses — Brazil, 2015. MMWR Morb Mortal Wkly Rep. 2016;65 (Early Release)(06):1-2. http://www.cdc.gov/mmwr/volumes/65/wr/mm6506e1.htm?s_cid=mm6506e1_e.  Published February 19, 2016.
4. European Centre for Disease Prevention and Control. Rapid risk assessment: Zika virus epidemic in the Americas: potential association with microcephaly and Guillain-Barré syndrome – 10 December 2015. http://ecdc.europa.eu/en/publications/Publications/zika-virus-americas-association-with-microcephaly-rapid-risk-assessment.pdf. Published 2015. Accessed Feb 1, 2016.
5. Dallas County Health and Human Services.  DCHHS reports first Zika virus case in Dallas County acquired through sexual transmission. February 2, 2016. http://www.dallascounty.org/department/hhs/press/documents/PR2-2-16DCHHSReportsFirstCaseofZikaVirusThroughSexualTransmission.pdf
6. Oduyebo T, Petersen EE, Rasmussen SA, et al. Update: interim guidelines for health care providers caring for pregnant women and women of reproductive age with possible Zika virus exposure—United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65.http://www.cdc.gov/mmwr/volumes/65/wr/mm6505e2.htm?s_cid=mm6505e2_e

For More Information

• General information about Zika virus and disease: http://www.cdc.gov/zika/
• Zika virus information for clinicians: http://www.cdc.gov/zika/hc-providers/index.html
• Protection against mosquitoes: http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/protection-against-mosquitoes-ticks-other-arthropods
• Travel notices related to Zika virus: http://wwwnc.cdc.gov/travel/notices
• Information about Zika virus for travelers and travel health providers: http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/zika
• HAN Advisory:  Recognizing, managing, and reporting Zika virus infections in travelers returning from Central America, South America, the Caribbean, and Mexico.  January 15, 2016.  http://emergency.cdc.gov/han/han00385.asp
• Pan American Health Organization PAHO): http://www.paho.org/hq/index.php?option=com_content&view=article&id=11585&Itemid=41688〈=en
• Approximate distribution of Aedes aegypti and Ae. albopictus mosquitoes in the United States:
  http://www.cdc.gov/chikungunya/resources/vector-control.html

The Centers for Disease Control and Prevention (CDC) protects people's health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national and international organizations.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

http://emergency.cdc.gov/han/han00388.asp