niman

Multiple cases worked in this region.

Although most resided outside of area, all were linked to identified area.

Area had high level of Aedis Egypti mosquitoes.

Focused in one small area where local transmission occurred in early July.

Florida has 4 cases of local Zika transmission - not unexpected. Zika is now here,

Gov. Rick Scott: 4 Zika cases likely came from Florida mosquitoesMike Schneider, Associated Press1:12 p.m. EDT July 29, 2016 (Photo: Andre Penner, AP) ORLANDO, Fla. (AP) — Florida likely has the first cases of Zika transmitted by mosquitoes on the U.S. mainland, the state's governor said Friday. No mosquitoes in the state have tested positive for Zika, but one woman and three men in Miami-Dade and Broward counties likely contracted the virus through mosquito bites, Gov. Rick Scott said during a news conference in Orlando. More than 1,650 Zika infections have been reported in the U.S., but the four patients in Florida would be the first not linked to travel outside the U.S. mainland. "This is not just a Florida issue. It's a national issue — we just happen to be at the forefront," Scott said. NAPLES DAILY NEWS 2 more mysterious Zika infections reported in South Florida Health officials believe the infections occurred in a small area just north of downtown Miami, in the popular Wynwood arts district, Scott said. It's the only part of the state currently being tested for potential local transmissions of Zika, Scott said. Women in the area who are pregnant or thinking about becoming pregnant are urged to contact their doctors and the county health department for Zika prevention kits. Federal health officials have not recommended that pregnant women avoid travel to South Florida. "There are a series of factors we'll have to look at. The number of cases, the relationship in geography of those cases, how closely linked they are in time, as well as a series of other factors that we will use to determine what recommendations we issue in terms of travel guidance," U.S. Surgeon General Dr. Vivek Murthy said Thursday. Zika primarily spreads through bites from tropical mosquitoes, but it also can be spread through sex. In most people, the virus causes only mild illness, but infection during pregnancy can lead to severe brain-related birth defects for the fetus. There is no vaccine. NAPLESNEWS Third case of Zika virus confirmed in Collier County Since February, over 380 Zika cases related to travel have been confirmed in Florida, including 151 cases in Miami-Dade and Broward counties. The tropical mosquito that spreads Zika and other viruses is found in the southern U.S. While health officials have predicted that mosquitoes in the continental U.S. would begin spreading Zika this summer, they also have said they expect only isolated clusters of infections and not widespread outbreaks. Florida should be able to contain the virus to an isolated area because its neighborhoods have better sanitation and living conditions than countries where Zika outbreaks have been widespread, said Adam Putnam, Florida's commissioner for agriculture and consumer services. The U.S. Food and Drug Administration has told blood centers in Miami-Dade and Broward counties to suspend collections until they can screen each unit of blood for the Zika virus with authorized tests. Neighboring counties have been urged to implement the same precautions, and visitors to South Florida in the last month are encouraged to defer donations as well. The FDA previously advised U.S. blood banks to refuse donations from people who recently traveled to areas outside the country that have Zika outbreaks. Florida's main supplier of blood, OneBlood, said it was working as quickly as possible to comply with the FDA's recommendation and would start testing all its collections for Zika on Friday. ___ Associated Press writers Jennifer Kay in Miami and Mike Stobbe in New York contributed to this report. http://www.naplesnews.com/story/news/local/florida/2016/07/29/gov-rick-scott-4-zika-cases-likely-came-florida-mosquitoes/87700702/

Fri Jul 29, 2016 1:15pm EDTRelated: U.S., HEALTHFlorida cases seen as first sign Zika transmitted locally in U.S.ORLANDO, FLA. | BY BARBARA LISTON Florida authorities on Friday reported what is believed to be the first evidence of local Zika transmission in the continental United States, concluding that mosquitoes likely infected four people with the virus that can cause rare but serious birth defects. Governor Rick Scott said the state believed active transmission of the virus was occurring within an area of the city about the size of a square mile (2.6 square kms). Testing showed that one woman and three men had been infected, Scott said. While health officials have yet to identify mosquitoes carrying the virus, the state has ruled out other means of transmission, including travel to another country with a Zika outbreak, and sexual contact. "We have worked hard to stay ahead of the spread of Zika and prepare for the worst," Scott said in a statement. "We will continue to put every resource available to fighting the spread of Zika in our state." Zika's greatest risk is believed to be posed by infection in pregnant women, given its ability to cause microcephaly in babies, a condition defined by small head size that can lead to developmental problems. The current outbreak was first detected in Brazil last year and has since spread rapidly through the Americas. Florida Surgeon General Celeste Philip said that health officials are not advising pregnant women in the transmission area to move. "We do not believe there will be ongoing transmission," Philip said at a press conference in Orlando, citing daily efforts to control the mosquito population in the area. The local health department is searching for other potential infections, with more than 2,300 people tested so far in the state, is ramping up mosquito control programs and is distributing Zika protection kits to pregnant women at their doctors' offices, Florida officials said. RELATED COVERAGE› Obama briefed on Zika cases in Florida, monitoring situationResidents in Miami neighborhoods thought to harbor Zika said that local spread of the virus had been inevitable, given the large numbers of tourists from other countries with outbreaks. Damian Jose Delgado, a 35-year-old father of two, said news of Zika's arrival would make him think twice about expanding his family. "I think I might be done having kids," Delgado said. EARLY WARNINGS U.S. health officials have cautioned for months that the summer mosquito season was likely to bring local outbreaks, with Gulf Coast states such as Florida, Texas and Louisiana, on the frontlines. Some have said Zika's spread could be more limited than in places like Brazil, given widespread use of screens on windows, air conditioning and mosquito control programs. The U.S. Centers for Disease Control and Prevention said on Friday that it would not recommend limiting travel to Florida. The agency has recommended that pregnant women not travel to other countries where Zika is active. "We anticipate that there may be additional cases of 'homegrown' Zika in the coming weeks," said Dr. Lyle Petersen, a CDC official helping lead the agency's Zika response effort. "Our top priority is to protect pregnant women from the potentially devastating harm caused by Zika." Up to 80 percent of people infected with Zika may experience no signs of illness, while those who do generally have relatively mild symptoms, including fever and rash. There are no specific treatments or vaccines for the virus. The World Health Organization declared a global health emergency in February, reflecting alarm over the discovery that Zika was linked to microcephaly and other severe neurological abnormalities. Brazil has confirmed over 1,600 cases of microcephaly linked to Zika infection in pregnant women. Public health officials say Zika is also a likely cause of Guillain-Barre syndrome, a rare neurological disorder in adults that can cause temporary paralysis. Zika's arrival in the United States comes with Congress in recess after failing to reach agreement over how much funding could be used to fight an outbreak. The Obama administration has requested $1.9 billion to finance research, mosquito control and other prevention efforts. Scott said he has authorized $26.2 million to help fight the virus in the state. Until now, the more than 1,600 Zika cases in the United States have stemmed from travel to another country with active transmission, as well as a small number of cases of apparent sexual transmission by a person infected outside of the country. Puerto Rico is grappling with a Zika outbreak, with more than 4,600 cases of local transmission. U.S. health officials have predicted there will be hundreds of thousands of cases on the island territory before the current outbreak ends due to the prevalence of Zika-carrying mosquitoes and a lack of infrastructure to protect against insect bites. (Additional reporting by Ankur Banerjee in Bengaluru, Zachary Fagenson in Miami; Writing by Michele Gershberg; Editing by Bernadette Baum and Paul Simao) http://www.reuters.com/article/us-health-zika-florida-idUSKCN1091NZ

Zika Cases in Florida Were Likely Spread by Mosquitoes, a First in the Continental U.S. By PAM BELLUCK, LIZETTE ALVAREZ and SABRINA TAVERNISEJULY 29, 2016 Continue reading the main storyShare This Page Share Tweet Email More Save Four cases of Zika infection in Miami are highly likely to have been caused by infected mosquitoes, the state Department of Health said Friday — the first documented instance of local transmission in the continental United States. Officials in Florida believe that the area of active transmission is limited to a one-square-mile area just north of downtown Miami. No mosquitoes tested have been found carrying the Zika virus, and the department is going door to door in the neighborhood collecting urine samples to test residents. Miami-Dade County is one of the busiest ports of entry into the United States from countries where the Zika virus is circulating. Health experts have long described it as one of the areas most at risk for an outbreak of the disease. Gov. Rick Scott said in a statement that the four cases involve three men and one woman. He did not indicate whether the woman was pregnant. “While no mosquitoes have tested positive for the Zika virus,” Mr. Scott said, the Health Department “is aggressively testing people in this area to ensure there are no other cases. If you live in this area and want to be tested, I urge you to contact the county health department.” Of the four people infected, he said, “They are all active Zika cases and have not exhibited symptoms to be admitted to the hospital.” The neighborhood that the authorities are focusing on is in the Wynwood area, bound by Northwest Fifth Avenue, U.S. 1, Northwest/Northeast 38th Street and Northwest/Northeast 20th Street. The virus, transmitted by mosquitoes or by sex with an infected person, causes brain damage and neurological disorders in babies born to mothers who contracted it in pregnancy. In rare cases, it can also cause a form of temporary paralysis. A mosquito’s range is short, said Dr. Chris Curry, a clinician and an assistant professor of obstetrics and gynecology at the University of Miami and Jackson Memorial Hospital, the county’s largest public hospital, who is in close contact with public health officials. “They tend to bite locally, ZIP code by ZIP code,” Dr. Curry said. Florida officials were at pains to describe the infections as a “small case cluster” that did not qualify as widespread transmission. The Centers for Disease Control and Prevention has recommended that pregnant women avoid areas in which there is widespread transmission of the Zika virus. The Florida cases signal a new stage in the epidemic. There are more than 1,600 confirmed Zika cases in the continental United States, but until the announcement on Friday, all of them had been a result of travel abroad — the virus was contracted either by a mosquito bite elsewhere or by sexual intercourse with someone who had been to a Zika-affected area. Zika has spread through dozens of countries in the Americas, afflicting hundreds of infants with a condition called microcephaly — abnormally small heads and brain damage. The infection is believed to contribute to variety of other neurological impairments. Public health officials had been bracing for locally transmitted cases. But the virus is not expected to spread rapidly in the continental United States, partly because Americans more often live in air-conditioned houses and are less exposed to mosquitoes. But the infection has been spreading quickly in Puerto Rico, where more than 5,000 cases have been confirmed. Experts suspect the real figure may be much higher. The outbreak is difficult to fight because 80 percent of those infected with the virus experience no symptoms. But even a small cluster of cases could have outsize effects if it includes anyone who is pregnant. A crucial part of stopping the outbreak is mosquito control, which is spotty at best in the United States, particularly in low income communities with weak tax bases. (Mosquito control is a local responsibility, though the C.D.C. has said it would help states hire contractors to conduct control work like spraying.) Officials across the country had been preparing for the first cases for months, beefing up mosquito control departments, doing drills, setting up trainings for health workers and pumping out messages to the public to keep their backyards clear of water-filled containers, which provide breeding grounds for the insects. State officials have complained, however, that they are hobbled by a lack of funding: Congress left for recess this month without passing President Obama’s $1.9 billion funding request to fight the virus. Dr. Thomas R. Frieden, the director of the C.D.C., has said that failure would significantly hamper federal public health efforts. In a phone call with Governor Scott last week, Mr. Obama said that the C.D.C. would give Florida $5.6 million in Zika funding, in addition to the $2 million the state has already received. In all, the agency has begun awarding $60 million to states, cities and territories, funds that will be available on Monday. Mr. Scott had used his emergency executive authority in June to allocate $26.2 million in state money for Zika preparedness, prevention and response. Despite its size, Miami-Dade County’s mosquito control budget had been very limited — far skimpier than some of the surrounding Florida counties with much smaller populations — and experts had long worried it would need more resources should a cluster of cases appear. Chalmers Vasquez, the county’s mosquito control manager, said he had been assured of the resources needed to fight Zika. His office has contracted additional employees, and more can be added if Zika becomes a bigger threat. “So far, it’s manageable,” he said, adding that he receives about 50 requests a day from residents for assistance. He added, “People are all waiting for Congress to approve the money.” Mr. Vasquez’s office was notified on Friday about one suspected case of locally acquired Zika. He led a team of six people to the location of the person infected with the virus. The team went into the front yard and backyard to look for mosquito breeding activity, peering into plants, like bromeliads, dumping containers with water and treating any standing water with insecticide. Workers also set traps to collect mosquitoes for analysis, spraying the areas by hand and applying larvicide. A mosquito spray truck was also sent into the area. They spent the weekend rolling out the same routine around the perimeter of the property — an area of 660 feet, which is about how far the mosquitoes that transmit Zika fly. The Aedes aegypti mosquito that carries the virus rarely flies farther than a few blocks in its short lifetime, and tends to stick close to homes, in gardens, and under chairs and couches. The mosquito has a limited range in the United States, rarely appearing farther north than the Deep South, Arizona and California. The C.D.C. released a 60-page document this year, a blueprint for action when the first cases of locally transmitted Zika occurred in the continental United States. The plan says officials should provide “a large margin of safety” by concentrating efforts within a one-mile circle around each known infection. One case, with no further transmission, would require a 45-day effort, the C.D.C. said. If the infection spreads, the agency will help local officials investigate and to warn residents; and, if needed, the agency will send in emergency teams. The Food and Drug Administration this week halted blood donations in South Florida until they can be screened for Zika infection. Jennifer Levin, a 32-year-old lawyer in Miami who is six months pregnant, said she was trying not to overreact to the news that local mosquitoes are spreading the Zika virus. To be cautious, she has followed her doctor’s advice: Apply mosquito spray (“I had never used bug spray in my life,” she said) and stay indoors after it rains and at sunset, when mosquitoes swarm. Ms. Levin said she was not traveling to places where Zika is found, like Puerto Rico. “I asked the doctor about it and he told me I had more chances of getting hurt in a car accident than contracting Zika,” Ms. Levin said. But, she added, “He said be smart.” http://www.nytimes.com/2016/07/30/health/zika-virus-florida-case.html?_r=0

White House Principal Deputy Press Secretary Eric Schultz says today's news on mosquito-bite Zika virus infections in Florida 'should be a wake-up call to Congress' to move on funding the fight against the virushttp://www.breakingnews.com/item/2016/07/29/white-house-principal-deputy-press-secretary-eric/

Press ReleaseEmbargoed Until: Friday, July 29, 2016 11:00 a.m. EDT Contact: Media Relations (404) 639-3286 As of July 7, Zika has been diagnosed in 5,582* people, including 672 pregnant women, in Puerto Rico according to a new report published today in theMorbidity and Mortality Weekly Report (MMWR). Positive tests for people with suspected Zika virus infection have increased from 14 percent in February to 64 percent in June. Positive tests through blood supply screening also increased, reaching 1.8 percent during the latest week of reporting starting July 3. “Puerto Rico is in the midst of a Zika epidemic. The virus is silently and rapidly spreading in Puerto Rico,” said Lyle R. Peterson, M.D., M.P.H, Incident Manager for CDC’s Zika Response and Director, Division of Vector-Borne Diseases. “This could lead to hundreds of infants being born with microcephaly or other birth defects in the coming year. We must do all we can to protect pregnant women from Zika and to prepare to care for infants born with microcephaly.” Many of the 5,582 people who tested positive for Zika virus infections were tested because they had symptoms of Zika. Because Zika infection during pregnancy can harm the developing fetus, pregnant women in Puerto Rico and other areas where Zika is spreading should be routinely tested during prenatal care whether or not they got sick. Of the 672 pregnant women, 441 (66 percent) experienced symptoms of Zika and 231 (34 percent) had no symptoms. Because approximately 80 percent of people infected with Zika do not have symptoms, the 672 pregnant women with evidence of Zika infection likely represent only a fraction of those who may be infected to date. In addition, 21 people with confirmed or suspected Guillain-Barré syndrome in Puerto Rico had evidence of Zika virus infection or recent unspecified flavivirus infection, and one person died after developing severe thrombocytopenia (low blood platelet count). Since local transmission of Zika virus was first reported in Puerto Rico in December 2015, it has become widespread on the island. People in 77 of 78 municipalities have tested positive for Zika virus infection. Large urban areas are most severely affected, with the largest numbers of diagnosed residents in the San Juan metropolitan area followed by the Ponce and Caguas metropolitan areas. Outbreaks of mosquito-borne viruses tend to peak in the late summer and fall in Puerto Rico—hotter months with higher rainfall—raising concern that Zika will continue to spread and increase in the coming months. At the current trend, hundreds to thousands more pregnant women in Puerto Rico could become infected with Zika by the end of the year. There is also risk for more Guillain-Barré syndrome cases associated with Zika virus infection. The situation in Puerto Rico warrants urgent, comprehensive action to protect pregnant women: The government of Puerto Rico and its municipalities can promote an integrated mosquito management program that includes reducing places with water where mosquitoes lay eggs, keeping mosquitoes out of houses with screens on windows and doors, and reducing the number of mosquitoes by using EPA-approved products. Everyone can follow these steps to help reduce the number of mosquitoes in and around homes.People who live in or travel to Puerto Rico should avoid mosquito bites by using EPA-registered insect repellents, wearing long-sleeved shirts and pants, and staying indoors in places with screens and air conditioning to the greatest extent possible.Pregnant women and their partners should use condoms and other barriers to prevent sexual transmission of Zika virus, or not have sex throughout the pregnancy.Couples who want to prevent or delay pregnancy should talk to their healthcare provider about safe and effective contraceptive methods. Clinicians who suspect Zika in patients who live in or have recently returned from areas with Zika, such as Puerto Rico, should report cases to public health officials.CDC is working with Puerto Rico to provide services to protect pregnant women from Zika, support pregnant women who have been infected with Zika, increase lab testing, improve mosquito control, and provide access to contraception for women who choose to delay or avoid pregnancy. CDC is also currently sponsoring the public education campaign in Puerto Rico Stop Zika to raise awareness of Zika virus and personal protective actions residents can take. * CDC only publishes data on our website that has been provided through ArboNET. Although Puerto Rico reports data to ArboNET, the Puerto Rico Department of Health reports cases from its own surveillance system, not ArboNET data. Differences in reporting between these surveillance systems contributes to different numbers being reported. http://www.cdc.gov/media/releases/2016/p0729-zika-infections-puerto-rico.html

ReferencesPetersen LR, Jamieson DJ, Powers AM, Honein MA. Zika Virus. N Engl J Med 2016;374:1552–63. CrossRef PubMedRasmussen SA, Jamieson DJ, Honein MA, Petersen LR. Zika virus and birth defects—reviewing the evidence for causality. N Engl J Med 2016;374:1981–7. CrossRef PubMedCao-Lormeau VM, Blake A, Mons S, et al. Guillain-Barré Syndrome outbreak associated with Zika virus infection in French Polynesia: a case-control study. Lancet 2016;387:1531–9.CrossRef PubMedSharp TM, Muñoz-Jordán J, Perez-Padilla J, et al. Zika virus infection associated with severe thrombocytopenia. Clin Infect Dis 2016;ciw476 Epub July 14, 2016. CrossRef PubMedKarimi O, Goorhuis A, Schinkel J, et al. Thrombocytopenia and subcutaneous bleedings in a patient with Zika virus infection. Lancet 2016;387:939–40. CrossRef PubMedThomas DL, Sharp TM, Torres J, et al. Local Transmission of Zika Virus—Puerto Rico, November 23, 2015–January 28, 2016. MMWR Morb Mortal Wkly Rep 2016;65:154–8. CrossRefPubMedDirlikov E, Ryff KR, Torres-Aponte J, et al. Update: ongoing Zika virus transmission—Puerto Rico, November 1, 2015–April 14, 2016. MMWR Morb Mortal Wkly Rep 2016;65:451–5.CrossRef PubMedSejvar JJ, Kohl KS, Gidudu J, et al. Guillain-Barré syndrome and Fisher syndrome: case definitions and guidelines for collection, analysis, and presentation of immunization safety data. Vaccine 2011;29:599–612. CrossRef PubMedSimeone RM, Shapiro-Mendoza CK, Meaney-Delman D, et al. Possible Zika virus infection among pregnant women—United States and territories, May 2016. MMWR Morb Mortal Wkly Rep 2016;65:514–9. CrossRef PubMedKuehnert MJ, Basavaraju SV, Moseley RR, et al. Screening of blood donations for Zika virus infection—Puerto Rico, April 3–June 11, 2016. MMWR Morb Mortal Wkly Rep 2016;65:627–8.CrossRef PubMedTepper NK, Goldberg HI, Bernal MI, et al. Estimating contraceptive needs and increasing access to contraception in response to the Zika virus disease outbreak—Puerto Rico, 2016. MMWR Morb Mortal Wkly Rep 2016;65:311–4. CrossRef PubMedBrogdon W, Chan A. Guidelines for evaluating insecticide resistance in vectors using the CDC bottle bioassay/methods in Anopheles research. Atlanta, GA: US Department of Health and Human Services, CDC; 2010. https://www.cdc.gov/malaria/resources/pdf/fsp/ir_manual/ir_cdc_bioassay_en.pdfLorenzi OD, Major C, Acevedo V, et al. Reduced incidence of chikungunya virus infection in communities with ongoing Aedes aegypti mosquito trap intervention studies—Salinas and Guayama, Puerto Rico, November 2015–February 2016. MMWR Morb Mortal Wkly Rep 2016;65:479–80. CrossRef PubMedBarrera R, Amador M, Acevedo V, Caban B, Felix G, Mackay AJ. Use of the CDC autocidal gravid ovitrap to control and prevent outbreaks of Aedes aegypti (Diptera: Culicidae). J Med Entomol 2014;51:145–54. CrossRef PubMedDuffy MR, Chen TH, Hancock WT, et al. Zika virus outbreak on Yap Island, Federated States of Micronesia. N Engl J Med 2009;360:2536–43. CrossRef PubMedFréour T, Mirallié S, Hubert B, et al. Sexual transmission of Zika virus in an entirely asymptomatic couple returning from a Zika epidemic area, France, April 2016. Euro Surveill 2016;21:30254.CrossRef PubMedPacheco O, Beltrán M, Nelson CA, et al. Zika virus disease in Colombia—preliminary report. N Engl J Med 2016. CrossRef PubMedSharp TM, Roth NM, Torres J, et al. . Chikungunya cases identified through passive surveillance and household investigations—Puerto Rico, May 5–August 12, 2014. MMWR Morb Mortal Wkly Rep 2014;63:1121–8. PubMedSharp TM, Hunsperger E, Santiago GA, et al. Virus-specific differences in rates of disease during the 2010 dengue epidemic in Puerto Rico. PLoS Negl Trop Dis 2013;7:e2159. CrossRefPubMedBrooks JT, Friedman A, Kachur RE, LaFlam M, Peters PJ, Jamieson DJ. Update: interim guidance. MMWR Morb Mortal Wkly Rep 2016;65:745–7. Epub July25, 2016. CrossRef PubMed Top * CDC Zika MAC-ELISA (http://www.fda.gov/downloads/MedicalDevices/Safety/EmergencySituations/UCM488044.pdf). † Trioplex RT-PCR test (http://www.fda.gov/downloads/MedicalDevices/Safety/EmergencySituations/UCM491592.pdf). § Zika Active Pregnancy Surveillance System is co-operated by PRDH and CDC. ¶ http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/Blood/UCM486360.pdf. ** http://www.salud.gov.pr/Estadisticas-Registros-y-Publicaciones/Informes%20Arbovirales/Forms/AllItems.aspx. †† http://www.salud.gov.pr/Estadisticas-Registros-y-Publicaciones/Pages/Reporte-de-Zika-por-Municipios.aspx. §§ http://www.cdc.gov/zika/prevention/. ¶¶ http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/Contraception.htm.

FIGURE 3. Percentage of screened blood donations reactive for Zika virus infection, by week of testing — Puerto Rico, April 3–July 3, 2016

FIGURE 2. Municipality of residence of persons with confirmed and presumptive Zika virus infection (n = 4,986) — Puerto Rico, November 1, 2015–July 7, 2016* * 596 additional cases were reported in persons with unknown municipality of residence.

FIGURE 1. Cases of confirmed and presumptive Zika virus infection (N = 5,582), by pregnancy status and week of illness onset or specimen collection, and percentage of persons with test results positive for Zika virus — Puerto Rico, November 1, 2015–July 7, 2016* * The decrease in cases for the first week of July 2016 might reflect a reporting delay.

TABLE 1. Pregnant women with test results positive for Zika virus infection — Puerto Rico, November 1, 2015–July 7, 2016Clinical statusConfirmed positive*Presumptive positive†Total testedSymptomatic383582,035Asymptomatic431887,308Total4262469,343* A confirmed case was defined as a positive result for Zika virus by reverse transcription–polymerase chain reaction testing. † A presumptive positive case was defined as a positive result by Zika virus immunoglobulin M enzyme-linked immunosorbent assay.

DiscussionBoth the number of Zika virus infections and percentage of tests among symptomatic persons and asymptomatic pregnant women that are positive are rapidly increasing in Puerto Rico. In addition, unspecified flavivirus cases, while indistinguishable by available laboratory tests, are likely attributable to Zika virus infection, as Zika virus is the predominant circulating flavivirus; Zika virus was identified in 5,351 suspected arboviral cases, compared with 136 dengue cases. Many persons with symptomatic Zika virus infection do not seek medical care or are not reported to public health officials, and most persons with Zika virus infection are asymptomatic (15), but can still infect mosquitoes and might unknowingly transmit the virus through sexual contact (16), blood donation (10), or vertically, to the fetus (17). The prevalence of Zika virus infection in Puerto Rico is substantial and increasing, with the most recent data indicating that 5% of asymptomatic pregnant women and 1.8% of blood donations have evidence of recent infection in the most recent reported week of screening (week beginning July 3) (10). Since the introduction of Zika virus to Puerto Rico in late 2015, the virus has spread to nearly all municipalities. The pattern of spread in Puerto Rico is consistent with that of newly introduced arboviruses into an immunologically naive population: transmission began in the heavily populated eastern region and subsequently spread to the southern and western parts of the island, with lower infection rates in the central mountainous regions (18,19). Arboviral outbreaks in Puerto Rico tend to peak in the late summer and fall, coincident with hotter months with higher rainfall, raising concern that the outbreak will continue and the incidence will increase during the coming months (18,19). Patterns observed after the introduction of other arboviruses into Puerto Rico, and evidence that the Zika virus outbreak exhibits no signs of abating, underscore the critical need for rapid, intensified measures to prevent infections among pregnant women. Surveillance data indicate that during June 2016, despite current interventions, approximately 322 pregnant women received diagnoses of having been newly infected in Puerto Rico, emphasizing the need for an aggressive, integrated vector management strategy coupled with intensive counseling and care for pregnant women. Measures to strengthen vector control in Puerto Rico include more intensive source reduction and larvicide application activities, community engagement, use of lethal adult mosquito traps, and consideration of strategies for vector control with insecticides to which local populations of Ae. aegypti are susceptible. A preliminary CDC evaluation of residual insecticide spraying indicates that adult mosquito populations in and around sprayed homes remained comparable to counts in and around unsprayed homes, probably as a result of movement of mosquitoes from nearby homes with breeding sources. Residents of and travelers to Puerto Rico should continue to employ mosquito bite avoidance behaviors, including using mosquito repellents, wearing long-sleeved shirts and pants, and ensuring that windows and doors have screens, and air conditioning is used, to avoid bites while indoors.§§ To reduce the risk for sexual transmission, especially to pregnant women, precautions should include consistent and correct use of condoms or abstinence (20).Women in Puerto Rico who do not desire pregnancy need access to effective and affordable voluntary contraception to avoid unintended pregnancies (11).¶¶ Clinicians who suspect Zika virus disease in patients who reside in or have recently returned from areas such as Puerto Rico with ongoing Zika virus transmission should consider testing for Zika virus and report cases to public health officials. Top AcknowledgmentsElba V. Caraballo, Chelsea G. Major, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; Office for State, Tribal, Local, and Territorial Support, CDC; Marrielle Mayshack, Office for State, Tribal, Local, and Territorial Support, CDC; Susan A. Galel, Roche Molecular Systems, Inc., Pleasanton, California.

Public Health ResponsePRDH, in collaboration with CDC, implemented a Zika virus response strategy with three focus areas: protecting pregnant women, controlling the mosquito vector, and expanding access to the full range of voluntary contraceptive options for women and men. Health messaging, such as television and radio public service announcements, has been implemented, health education materials have been distributed at locations, including health care facilities and community events, and weekly arboviral surveillance reports with island-wide and municipal-level information have been posted online.**,†† Outreach to travelers has included health messaging via television screens and flyers at ports of entry, hotels, and tourist places of interest as well as training airport and tourism personnel. Community intervention strategies have focused on pregnant women. PRDH has worked closely with Women, Infants, and Children (WIC) clinics, where 90% of pregnant women residing in Puerto Rico received services in 2015 (Dana Miró Medina, LND, WIC Puerto Rico, personal communication, 2016), to provide approximately 12,900 Zika prevention kits to pregnant women; the kits include insect repellent, bed nets, condoms, and larvicide to prevent mosquito breeding sites in water-holding containers around households. Since February 2016, approximately 21,000 pregnant women, representing approximately 67% of the estimated number of pregnant women per year based on 2015 birth rates, have been counseled about Zika virus prevention at WIC clinics. In addition, to reduce the risk for unintended pregnancies, the public health response includes community outreach and education about sexual transmission of Zika virus, distribution of male and female condoms, and an increase in the availability of the full range of voluntary contraceptive methods, including long-acting reversible contraceptives (11). PRDH and CDC have also implemented a representative, population-based survey of women aged 18–49 years to assess contraception use through the Behavioral Risk Factor Surveillance System. Pregnant women across the island identified through WIC are offered vector control services carried out by a contracted pest control company; these services include source reduction of mosquito breeding sites, larvicide application, and residual indoor and outdoor insecticide spraying with deltamethrin. The Puerto Rico Public Housing Administration has led programs to incorporate residual insecticide spraying with deltamethrin and, in collaboration with Puerto Rico Department of Family Affairs, is working to install screens in the homes of pregnant women. During February–March 2016, a CDC laboratory in Puerto Rico conducted an insecticide resistance study of Ae. aegypti mosquitoes to guide vector control strategies. Mosquitoes from across Puerto Rico were tested using the CDC bottle bioassay (12). Results from the laboratory study indicated widespread resistance to pyrethroids throughout the island with the exception of partial resistance to deltamethrin and full susceptibility to naled, an organophosphate insecticide. Insecticide resistance surveillance is ongoing in the CDC laboratory. Use of lethal adult mosquito traps, which have previously been associated with reduced Ae. aegypti numbers and incidence of arboviral infections in Puerto Rico, is also under consideration (13,14). PRDH and CDC have collaborated to ensure that all public schools are sprayed with deltamethrin before the school year starts in early August. Furthermore, PRDH and the Puerto Rico Emergency Management Agency have collaborated with municipalities to initiate community cleanup campaigns using larvicide to prevent mosquito breeding in water-holding containers around households and to remove mosquito breeding sites, such as trash heaps and septic tanks. In addition, the Puerto Rico Emergency Management Agency and the Puerto Rico Environmental Quality Board have removed approximately 1.6 million rubber tires that could act as mosquito breeding sites. Women with evidence of Zika virus infection during pregnancy and their exposed offspring are monitored for adverse maternal, fetal, neonatal, infant, and child health outcomes through the Zika Active Pregnancy Surveillance System. Puerto Rico’s Birth Defects Surveillance and Prevention System, in collaboration with maternal fetal medicine specialists, monitors the ultrasound findings of pregnant women infected with Zika virus. Beginning in January 2016, the Birth Defects Surveillance and Prevention System began identifying newborns with congenital microcephaly, including those born to women infected with Zika virus during pregnancy. All newborns of women with evidence of Zika virus infection during pregnancy are referred to the Children with Special Health Care Needs program for developmental surveillance and coordinated specialized services, for up to age 3 years as needed. All newborns with congenital microcephaly will be referred to Avanzando Juntos, Puerto Rico's early intervention services system.

Epidemiologic SurveillanceEpidemiologic surveillance for Zika virus in Puerto Rico has previously been described, and includes testing of all symptomatic persons for evidence of Zika, dengue, or chikungunya virus infection using the Trioplex RT-PCR† or MAC-ELISA tests (7). During November 1, 2015–July 7, 2016, specimens from 16,522 symptomatic patients with suspected arboviral disease were evaluated. A total of 5,106 (31%) confirmed and 245 (1%) presumptive Zika virus infections were identified. In addition, test results for 136 (<1%) patients were positive for recent dengue virus infection, results for 127 (<1%) were positive for recent unspecified flavivirus infection, and results for 100 (<1%) were positive for recent chikungunya virus infection. Among the 5,351 symptomatic patients with evidence of recent Zika virus infection, 441 (8%) were pregnant women (Table 1). Thirty-six confirmed or suspected cases of GBS (8) were reported to PRDH by providers throughout the island. Among these patients, 21 (61%) had evidence of Zika virus or flavivirus infection, including five (14%) with confirmed and 11 (33%) with presumptive Zika virus infections, and five (14%) with unspecified flavivirus infections. Sixty-five (<1%) of 5,131 symptomatic patients with confirmed or presumptive Zika virus infection required hospitalization, including all GBS patients. One male patient with Zika virus infection died of complications related to severe thrombocytopenia (4). Sixty-five infants were born to women with evidence of Zika virus infection in pregnancy, and two pregnancy losses were identified. In one pregnancy loss, Zika virus was identified in neural tissue by immunohistochemistry. No cases of congenital Zika virus infection among live births in Puerto Rico have been identified. All pregnant women with confirmed or presumptive Zika virus infection, or unspecified flavivirus infection, and their prenatally exposed offspring are being actively monitored for adverse maternal, fetal, neonatal, infant, and child health outcomes through the Zika Active Pregnancy Surveillance System,§ a collaboration between PRDH and CDC. PRDH has followed CDC recommendations that pregnant women in areas with evidence of active Zika virus transmission receive screening tests during the first and second trimesters of pregnancy, regardless of symptoms (9). Among 7,308 asymptomatic pregnant women tested during January–July 2016, 43 (<1%) confirmed and 188 (3%) presumptive Zika virus infections were identified. The percentage of asymptomatic pregnant women with confirmed or presumptive recent Zika virus infection among women tested increased almost sixfold, from 0.8% in February 2016 to 5.3% in June 2016. The number of Zika virus infections reported each week in Puerto Rico gradually increased during November 2015–February 2016, and remained relatively stable until April 2016 (Figure 1). The number of persons with recent Zika virus infection reported each week began to increase in April 2016, and steadily increased through June. Overall, Puerto Rico reported 291 new confirmed and presumptive Zika virus cases during February 2016; 2,612 new confirmed and presumptive Zika virus cases were reported during June, a nearly eightfold increase. Among symptomatic males and nonpregnant females who were tested, the percentage of persons with confirmed or presumptive Zika virus infection increased fourfold from 14% in February to 64% in June; during the same time, the percentage of persons with confirmed or presumptive Zika virus infection among symptomatic pregnant women increased fourfold, from 8% to 41%. Suspected cases of Zika virus disease were reported in all 78 municipalities, and Zika virus–infected patients were residents of 77 (99%) municipalities (Figure 2). The more populous municipalities of San Juan and Ponce reported the highest numbers of confirmed and presumptive Zika virus cases, with fewer cases occurring in the rural municipalities of Puerto Rico. On April 3, 2016, local collection of blood donation specimens resumed (the Food and Drug Administration had recommended cessation of blood collection in areas of the United States affected by active vectorborne transmission of Zika virus and importation of all blood components from the continental United States beginning March 5¶). Zika virus screening using a nucleic acid test (cobas Zika, Roche Molecular Systems, Inc., Pleasanton, California) was authorized by the Food and Drug Administration under an investigational new drug application (10). A blood donation specimen with an initial reactive result by nucleic acid testing is regarded as presumptive positive for Zika virus infection. During the weeks of April 3 through July 3, among 18,163 donation specimens tested, 143 (0.8%) were identified as presumptive positive for Zika virus. The percentage of blood donation specimens testing positive by week has increased, with the highest percentage (1.8%) occurring during the latest week of reporting (week beginning July 3) (Figure 3).

Zika virus is a flavivirus transmitted primarily by Aedes aegypti and Aedes albopictus mosquitoes, and infection can be asymptomatic or result in an acute febrile illness with rash (1). Zika virus infection during pregnancy is a cause of microcephaly and other severe birth defects (2). Infection has also been associated with Guillain-Barré syndrome (GBS) (3) and severe thrombocytopenia (4,5). In December 2015, the Puerto Rico Department of Health (PRDH) reported the first locally acquired case of Zika virus infection. This report provides an update to the epidemiology of and public health response to ongoing Zika virus transmission in Puerto Rico (6,7). A confirmed case of Zika virus infection is defined as a positive result for Zika virus testing by reverse transcription–polymerase chain reaction (RT-PCR) for Zika virus in a blood or urine specimen. A presumptive case is defined as a positive result by Zika virus immunoglobulin M (IgM) enzyme-linked immunosorbent assay (MAC-ELISA)* and a negative result by dengue virus IgM ELISA, or a positive test result by Zika IgM MAC-ELISA in a pregnant woman. An unspecified flavivirus case is defined as positive or equivocal results for both Zika and dengue virus by IgM ELISA. During November 1, 2015–July 7, 2016, a total of 23,487 persons were evaluated by PRDH and CDC Dengue Branch for Zika virus infection, including asymptomatic pregnant women and persons with signs or symptoms consistent with Zika virus disease or suspected GBS; 5,582 (24%) confirmed and presumptive Zika virus cases were identified. Persons with Zika virus infection were residents of 77 (99%) of Puerto Rico’s 78 municipalities. During 2016, the percentage of positive Zika virus infection cases among symptomatic males and nonpregnant females who were tested increased from 14% in February to 64% in June. Among 9,343 pregnant women tested, 672 had confirmed or presumptive Zika virus infection, including 441 (66%) symptomatic women and 231 (34%) asymptomatic women. One patient died after developing severe thrombocytopenia (4). Evidence of Zika virus infection or recent unspecified flavivirus infection was detected in 21 patients with confirmed GBS. The widespread outbreak and accelerating increase in the number of cases in Puerto Rico warrants intensified vector control and personal protective behaviors to prevent new infections, particularly among pregnant women.

SummaryWhat is already known about this topic? Zika virus transmission in Puerto Rico has been increasing since it was first detected in November 2015. Zika virus infection is a cause of microcephaly and other severe birth defects and has been associated with Guillain-Barré syndrome and severe thrombocytopenia. What is added by this report? During November 1, 2015–July 7, 2016, specimens from 16,522 patients with suspected Zika virus disease in Puerto Rico were evaluated and 5,351 (32%) had laboratory evidence of current or recent Zika virus infection. The percentage of persons with confirmed or presumptive Zika virus infection among symptomatic pregnant females increased from 8% in February 2016 to 41% in June 2016; during the same time, the percentage of persons with confirmed or presumptive Zika virus infection among symptomatic males and nonpregnant females increased from 14% to 64%. The public health response includes increased surveillance for Zika virus infection, preventing infection in pregnant women, monitoring infected pregnant women and their fetuses for adverse outcomes, controlling mosquitoes, assuring the safety of blood products, and expanding access to the full range of voluntary contraceptive options for women and men. What are the implications for public health practice? The Zika virus outbreak in Puerto Rico continues to expand in geographic extent and number of infected persons. Residents of and travelers to Puerto Rico should continue to employ mosquito bite avoidance behaviors, take precautions to reduce the risk for sexual transmission, and seek medical care for any acute illness with rash or fever. Intensified vector control measures, including an integrated vector management strategy, are needed to help reduce disease spread. Clinicians who suspect Zika virus disease in patients who reside in or have recently returned from areas with ongoing Zika virus transmission should consider testing for Zika virus and report cases to public health officials.

Laura Adams, DVM1; Melissa Bello-Pagan, MS2; Matthew Lozier, PhD1; Kyle R. Ryff, MPH2; Carla Espinet, MPH2; Jomil Torres, MS2; Janice Perez-Padilla, MPH1; Mitchelle Flores Febo, MS1,2; Emilio Dirlikov, PhD2,3; Alma Martinez, MPH4; Jorge Munoz-Jordan, PhD1; Myriam Garcia5,6; Marangely Olivero Segarra, MS5,6; Graciela Malave5,6; Aidsa Rivera, MS1; Carrie Shapiro-Mendoza, PhD7; Asher Rosinger, PhD3,8; Matthew J. Kuehnert, MD9; Koo-Whang Chung, MPH9; Lisa L. Pate, MD10; Angela Harris, PhD1; Ryan R. Hemme, PhD1; Audrey Lenhart, PhD11; Gustavo Aquino, MPH12; Sherif Zaki, MD13; Jennifer S. Read, MD1; Stephen H. Waterman, MD1; Luisa I. Alvarado, MD14; Francisco Alvarado-Ramy, MD15; Miguel Valencia-Prado, MD4; Dana Thomas, MD2,16; Tyler M. Sharp, PhD1; Brenda Rivera-Garcia, DVM2 Corresponding author: Laura Adams, [email protected], 787-706-2249. Top 1Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 2Office of Epidemiology and Research, Puerto Rico Department of Health;3Epidemic Intelligence Service, Division of Scientific Education and Professional Development, CDC; 4Puerto Rico Birth Defects Surveillance and Prevention System, Puerto Rico Department of Health; 5Biological and Chemical Emergencies Laboratory, Office of Public Health Preparedness and Response, Puerto Rico Department of Health; 6Public Health Laboratory, Puerto Rico Department of Health; 7Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; 8Division of Health and Nutrition Examination Surveys, National Center for Health Statistics; 9Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 10Roche Molecular Systems, Inc., Pleasanton, California; 11Entomology Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, CDC; 12Office of the Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; 13Infectious Diseases Pathology Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 14Ponce Health Sciences University-Saint Luke’s Episcopal Hospital Consortium, Puerto Rico; 15Division of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 16Division of State and Local Readiness, Office of Public Health Preparedness and Response, CDC.

Update: Ongoing Zika Virus Transmission — Puerto Rico, November 1, 2015–July 7, 2016Early Release / July 29, 2016 / 65 http://www.cdc.gov/mmwr/volumes/65/wr/mm6530e1.htm?s_cid=mm6530e1_e

JULY 29, 2016 10:11 AM Local transmission of Zika by mosquitoes confirmed in Miami Miami-Dade mosquito-control workers scour county in fight against Zika 2:04 FACEBOOK TWITTER EMAIL SHARE 1 of 3Florida Gov. Rick Scott said Friday morning that Zika virus is being transmitted by local mosquitoes in a one-square-mile area north of Downtown Miami. The exact location identified as having active Zika transmission is within Northwest 5th Avenue to the west, U.S. 1 to the east, Northwest/Northeast 38th Street to the north and Northwest/Northeast 20th Street to the south.BY DANIEL CHANG [email protected] LINKEDINGOOGLE+PINTERESTREDDITPRINTORDER REPRINT OF THIS STORY Zika virus is actively being transmitted by local mosquitoes in a one-square-mile area just north of Downtown Miami, Florida Gov. Rick Scott said Friday morning in confirming that four cases of Zika infection in Miami-Dade and Broward counties were acquired locally. The exact location identified as having active Zika transmission is within Northwest 5th Avenue to the west, U.S. 1 to the east, Northwest/Northeast 38th Street to the north and Northwest/Northeast 20th Street to the south. Interactive feature: Daily Florida Zika virus trackerThis is currently the only area of the state where the Florida Department of Health is testing to see if there local mosquitoes are spreading Zika. All four of Florida’s cases — two in Miami-Dade and two in Broward — are active Zika cases but none of the people inected have exhibited symptoms to be admitted to the hospital. “We learned today that four people in our state likely have the Zika virus as a result of a mosquito bite,” Scott said in confirming the locally acquired cases. The first suspected local case was announced in Miami-Dade on July 19, and the second in Broward on July 21. On Wednesday, the health department announced two more suspected cases in both counties. The health department reported two new travel-related casesThursday, both involving pregnant women, raising the statewide total to 383 people who have contracted the virus this year, including 55 expectant mothers. Pregnant women are considered to be at the greatest risk from the Zika virus because it can cause microcephaly and other birth defects. No mosquitoes in Florida have tested positive for the Zika virus to date, Scott said. But the health department is testing people in the area in search of other cases. The health department urged people who live in the area north of downtown and want to be tested to contact the Miami-Dade agency at 305-324-2400 for more information. FACEBOOK TWITTER EMAIL SHARE How Zika spreads (and who’s to blame)The mosquito kills nearly 750,000 people each year. Malaria is the cause for the majority of these deaths, but a Zika outbreak has the Americas scared of this insect. This is how the insect spreads disease to its victims. Sohail Al-Jamea and Meta Viers McClatchy In confirming local transmission of Zika, Scott said he directed the health department to immediately begin contracting with commercial pest control companies to increase spraying and mosquito reduction efforts in the impacted area. The governor also directed the health department to activate the Joint Information Center within the state’s Emergency Operations Center to ensure impacted areas have coordinated access to information and resources. Scott also ordered that Florida: • Provide $620,000 to OneBlood, the primary blood bank in the area, to establish appropriate blood screening. OneBlood began screening all blood donations for Zika virus on Friday. • Work with the Department of Agriculture and Consumer Services to issue a Mosquito Declaration and ensure that Mosquito Control in the areas of concern have the resources they need to combat further local transmission. Miami-Dade and Broward County Mosquito Control Districts will receive $1.28 million in state funds through December to combat Zika. • Continue investigations in concert with the Centers for Disease Control and Prevention to ensure we learn all we can about Zika as an emerging disease. • Coordinate with OB/GYNs and organizations that serve pregnant woman in the impacted area to distribute Zika prevention kits to pregnant women. • Ongoing door-to-door outreach in the areas of concern with continued mosquito mitigation activities and repellant distribution. • Partner with VISIT FLORIDA to distribute educational items, repellant and Zika Prevention Kits for pregnant women to visitor centers in the impacted areas. • Partner with the Florida Department of Education to ensure that mosquito breeding source reduction and mitigation activities have occurred at all schools in Miami-Dade and Broward counties ahead of children returning to classes this fall.(305) 575-3800 Daniel Chang: 305-376-2012, @dchangmiami ZIKA CASES REPORTED IN FLORIDA AS OF JULY 28 County Number of Cases Alachua 5 Brevard 8 Broward** 55 Charlotte 1 Citrus 2 Clay 3 Collier 4 Duval 6 Escambia 2 Highlands 1 Hillsborough 10 Lake 1 Lee 6 Manatee 1 Martin 1 Miami-Dade** 96 Okaloosa 2 Okeechobee 1 Orange 40 Osceola 18 Palm Beach 18 Pasco 6 Pinellas 7 Polk 12 Santa Rosa 1 Seminole 12 St. Johns 3 St. Lucie 1 Volusia 5 Total cases not involving pregnant women 328 Cases involving pregnant women regardless of symptoms* 55 * Counties of pregnant women not disclosed. ** Does not included suspected cases of local transmission. Source: Florida Department of Health http://www.miamiherald.com/news/health-care/article92566182.html Read more here: http://www.miamiherald.com/news/health-care/article92566182.html#storylink=cpy