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Annemiek A. van der Eijk, M.D., Ph.D. Erasmus Medical Center, Rotterdam, the Netherlands [email protected] Perry J. van Genderen, M.D., Ph.D. Harbour Hospital, Rotterdam, the Netherlands Rob M. Verdijk, M.D., Ph.D. Chantal B. Reusken, Ph.D. Ramona Mögling, Ph.D. Jeroen J.A. van Kampen, M.D., Ph.D. Widagdo Widagdo, M.D. Georgina I. Aron, B.Sc. Corine H. GeurtsvanKessel, M.D., Ph.D. Suzan D. Pas, Ph.D. V. Stalin Raj, Ph.D. Bart L. Haagmans, Ph.D. Marion P.G. Koopmans, D.V.M., Ph.D. Erasmus Medical Center, Rotterdam, the Netherlands Supported by the Horizon 2020 research and innovation program of the European Union (grant agreement no. 643476) and by the European Virus Archive Goes Global project, which received a grant (653316) from the European Union Horizon 2020 Framework Program for Research and Innovation. Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. Drs. van der Eijk, van Genderen, and Verdijk contributed equally to this letter. This letter was published on July 27, 2016, at NEJM.org.

CORRESPONDENCE Miscarriage Associated with Zika Virus InfectionJuly 27, 2016DOI: 10.1056/NEJMc1605898 http://www.nejm.org/doi/full/10.1056/NEJMc1605898?query=featured_home

Registration Date: 27/07/2016 18:07:27 the amended 07/27/2016 18:07:27 thehttp://portalsaude.saude.gov.br/index.php/cidadao/principal/agencia-saude/24769-microcefalia-1-749-casos-confirmados-no-brasil REPORT CARD Microcephaly: 1,749 confirmed cases in BrazilThe weekly report gathers information submitted by state health departments until 23 July. Other 3,062 cases remain under investigation New bulletin of the Ministry of Health, released on Wednesday (27), points out that, until July 23, were confirmed 1,749 cases of microcephaly and other nervous system disorders, suggestive of congenital infection.They remain under investigation by the Ministry of Health and the states 3,062 suspected cases of microcephaly across the country. Since the beginning of the investigation, in October last year, 8,703 cases were reported to the Ministry of Health. Of these, 3,892 were discarded because of normal tests, or because they have microcephaly or malformations confirmed because noninfectious. They were also discarded by do not meet the case definition. Of the total confirmed cases (1,749), 272 were confirmed by specific laboratory criteria for Zika virus. The Ministry of Health, however, points out that this figure does not represent adequately the total number of cases related to the virus. The folder considers that there was infection Zika most of the mothers who had babies with a final diagnosis of microcephaly. The 1,749 confirmed cases in Brazil occurred in 609 municipalities located in all Brazilian states and the Federal District. In the same period, there were 371 suspected deaths of microcephaly and / or alteration of the central nervous system after birth or during pregnancy (miscarriage or stillbirth) in the country. This represents 4.3% of the total reported cases. Of these, 106 were confirmed to microcephaly and / or alteration of the central nervous system.Another 200 are still under investigation and 65 were discarded. The Ministry of Health says it is investigating all cases of microcephaly and other disorders of the central nervous system informed by the states, as well as possible relationship with the Zika virus and other congenital infections.Microcephaly can be caused by various infectious agents beyond Zika as Syphilis, Toxoplasmosis, Other Infectious Agents, Rubella, Cytomegalovirus and Herpes Viral. The folder guides pregnant women adopt measures to reduce the presence of Aedes aegypti, with the elimination of breeding sites, and protect themselves from mosquito exposure, keeping doors and closed or screened windows, wear pants and long sleeved shirts and use allowed repellents for pregnant women. Distribution of reported cases of microcephaly by UF until July 23, 2016 Regions and Federative Units Microcephaly cases and / or malformations suggestive of congenital infection Total accumulated 1 of reported cases from 2015 to 2016 research confirmed 2.3 discarded 4 Brazil 3,062 1,749 3,892 8,703 Alagoas 63 79 189 331 Bahia 652 282 284 1,218 Ceará 152 136 260 548 Maranhão 93 134 62 289 Paraíba 249 155 494 898 Pernambuco 398 376 1,300 2,074 Piauí 12 92 74 178 large northern river 191 123 135 449 Sergipe 76 117 57 250 Northeast 1,886 1,494 2,855 6,235 Holy Spirit 88 22 68 178 Minas Gerais 68 4 63 135 Rio de Janeiro 317 95 187 599 Sao Paulo 365 11 189 565 Southeast 838 132 507 1,477 Acre 12 two 30 44 Amapá two 7 4 13 Amazon 13 8 5 26 For 56 1 0 57 Rondonia * 4 5 9 18 Roraima 4 10 13 27 Tocantins 63 17 88 168 North 154 50 149 353 Federal district 4 6 39 49 Goiás 39 15 95 149 Mato Grosso 92 36 128 256 Mato Grosso do Sul 10 5 14 29 Midwest 145 62 276 483 Paraná 0 4 37 41 Santa Catarina 3 1 6 10 Rio Grande do Sul 36 6 62 104 South 39 11 105 155 By Camila Bogaz, the Agency Health Care to press (61) 3315-3435 / 3580

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Honduras: Another case of microcephaly linked to zikachronic TN8eventsBy La Tribuna - July 27, 2016, 9:27 a.m.219Photo: El HeraldoAuthorities Health in Honduras report the birth of a baby with microcephaly , adding nine cases linked to the virus zika . El Salvador: Captured alleged gang members with gunsThe head of the Ministry of Health, Yolani Batres, said Wednesday that investigates a ninth case ofmicrocephaly linked to the virus zika . The Minister said the birth last Tuesday night was recorded in Choloma, Cortés. "You have to do lab tests and document the medical history of the mother," she said. He said the virus zika entered the country through the southern border, where up to date , eight were investigated cases of microcephaly . "The zika jumped in the south and went to the Valley of Sula, that is the epidemiological history , " said the headline. He recalled that three of the mothers attended in Choluteca presented symptoms of suffering zika. "Of the six women he had three of them zika, there is a very strong which has been repeated in Brazil, Colombia and Panama epidemiological link , " he said. On the ninth case of microcephaly linked to zika , he has described in detail that must do more analysis. Also the representative of Health called on the population to fight the mosquito transmitter of the virus because it is a constant struggle. "If we do not clean the house once a week is difficult to fight these diseases , " he said, referring to zika , dengue and chikungunya. The southern region of Honduras remains on alert for the birth of six babies with microcephaly. The virus zika , which is mainly spread through the mosquito Aedes aegypti, is associated with malformations in fetuses, such as microcephaly , and neurological disorders such as Guillain-Barre syndrome. Seven of the children with microcephaly born in the city Choluteca, one in Tegucigalpa and now one in Choloma. http://www.tn8.tv/cronica-tn8/333481-honduras-otro-caso-microcefalia-vinculado-zika/

Honduras: Another case of microcephaly linked to zikachronic TN8eventsBy La Tribuna - July 27, 2016, 9:27 a.m.219Photo: El HeraldoAuthorities Health in Honduras report the birth of a baby with microcephaly , adding nine cases linked to the virus zika . El Salvador: Captured alleged gang members with gunsThe head of the Ministry of Health, Yolani Batres, said Wednesday that investigates a ninth case ofmicrocephaly linked to the virus zika . The Minister said the birth last Tuesday night was recorded in Choloma, Cortés. "You have to do lab tests and document the medical history of the mother," she said. He said the virus zika entered the country through the southern border, where up to date , eight were investigated cases of microcephaly . "The zika jumped in the south and went to the Valley of Sula, that is the epidemiological history , " said the headline. He recalled that three of the mothers attended in Choluteca presented symptoms of suffering zika. "Of the six women he had three of them zika, there is a very strong which has been repeated in Brazil, Colombia and Panama epidemiological link , " he said. On the ninth case of microcephaly linked to zika , he has described in detail that must do more analysis. Also the representative of Health called on the population to fight the mosquito transmitter of the virus because it is a constant struggle. "If we do not clean the house once a week is difficult to fight these diseases , " he said, referring to zika , dengue and chikungunya. The southern region of Honduras remains on alert for the birth of six babies with microcephaly. The virus zika , which is mainly spread through the mosquito Aedes aegypti, is associated with malformations in fetuses, such as microcephaly , and neurological disorders such as Guillain-Barre syndrome. Seven of the children with microcephaly born in the city Choluteca, one in Tegucigalpa and now one in Choloma. http://www.tn8.tv/cronica-tn8/333481-honduras-otro-caso-microcefalia-vinculado-zika/

Honduras: Another case of microcephaly linked to zikachronic TN8eventsBy La Tribuna - July 27, 2016, 9:27 a.m.219Photo: El HeraldoAuthorities Health in Honduras report the birth of a baby with microcephaly , adding nine cases linked to the virus zika . El Salvador: Captured alleged gang members with gunsThe head of the Ministry of Health, Yolani Batres, said Wednesday that investigates a ninth case ofmicrocephaly linked to the virus zika . The Minister said the birth last Tuesday night was recorded in Choloma, Cortés. "You have to do lab tests and document the medical history of the mother," she said. He said the virus zika entered the country through the southern border, where up to date , eight were investigated cases of microcephaly . "The zika jumped in the south and went to the Valley of Sula, that is the epidemiological history , " said the headline. He recalled that three of the mothers attended in Choluteca presented symptoms of suffering zika. "Of the six women he had three of them zika, there is a very strong which has been repeated in Brazil, Colombia and Panama epidemiological link , " he said. On the ninth case of microcephaly linked to zika , he has described in detail that must do more analysis. Also the representative of Health called on the population to fight the mosquito transmitter of the virus because it is a constant struggle. "If we do not clean the house once a week is difficult to fight these diseases , " he said, referring to zika , dengue and chikungunya. The southern region of Honduras remains on alert for the birth of six babies with microcephaly. The virus zika , which is mainly spread through the mosquito Aedes aegypti, is associated with malformations in fetuses, such as microcephaly , and neurological disorders such as Guillain-Barre syndrome. Seven of the children with microcephaly born in the city Choluteca, one in Tegucigalpa and now one in Choloma. http://www.tn8.tv/cronica-tn8/333481-honduras-otro-caso-microcefalia-vinculado-zika/

Honduras: Another case of microcephaly linked to zikachronic TN8eventsBy La Tribuna - July 27, 2016, 9:27 a.m.219Photo: El HeraldoAuthorities Health in Honduras report the birth of a baby with microcephaly , adding nine cases linked to the virus zika . El Salvador: Captured alleged gang members with gunsThe head of the Ministry of Health, Yolani Batres, said Wednesday that investigates a ninth case ofmicrocephaly linked to the virus zika . The Minister said the birth last Tuesday night was recorded in Choloma, Cortés. "You have to do lab tests and document the medical history of the mother," she said. He said the virus zika entered the country through the southern border, where up to date , eight were investigated cases of microcephaly . "The zika jumped in the south and went to the Valley of Sula, that is the epidemiological history , " said the headline. He recalled that three of the mothers attended in Choluteca presented symptoms of suffering zika. http://www.tn8.tv/cronica-tn8/333481-honduras-otro-caso-microcefalia-vinculado-zika/ "Of the six women he had three of them zika, there is a very strong which has been repeated in Brazil, Colombia and Panama epidemiological link , " he said. On the ninth case of microcephaly linked to zika , he has described in detail that must do more analysis. Also the representative of Health called on the population to fight the mosquito transmitter of the virus because it is a constant struggle. "If we do not clean the house once a week is difficult to fight these diseases , " he said, referring to zika , dengue and chikungunya. The southern region of Honduras remains on alert for the birth of six babies with microcephaly. The virus zika , which is mainly spread through the mosquito Aedes aegypti, is associated with malformations in fetuses, such as microcephaly , and neurological disorders such as Guillain-Barre syndrome. Seven of the children with microcephaly born in the city Choluteca, one in Tegucigalpa and now one in Choloma.

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And are 9 cases of microcephaly by zika in HondurasLast night a baby was born with microcephaly in the public hospital in Puerto Cortes.AddThis Sharing Buttons By: laprensa.hn Last night was born a child with microcephaly associated with the Zika virus, transmitted by the aedes aegypti mosquito disease, in the hospital of Puerto Cortes. Health Minister, Yolani Batres said they are doing case studies to confirm whether this case is the zika microcephaly. Zika virus is associated with fetal malformations such as microcephaly, and neurological disorders such as Guillain-Barre syndrome. He also recalled that "we are in a health emergency against the mosquito transmitter dengue and chikungunya zika". http://www.estrategiaynegocios.net/centroamericaymundo/centroamerica/honduras/984061-330/ya-son-9-casos-de-microcefalia-por-zika-en-honduras?utm_source=twitterfeed&utm_medium=twitter&utm_campaign=redessociales

Puerto Cortez http://www.laprensa.hn/honduras/984348-410/honduras-alerta-nacional-por-bebés-con-microcefalia

Florida expands probe of potential local casesIn its daily Zika update, meanwhile, Florida Health said it is expanding its investigation to include the two more possible locally acquired cases, which are from Broward and Miami-Dade counties. The two locations are also the sites of the two suspected local cases reported last week. Officials said a probe of the new cases began today with door-to-door outreach and sample collection, and they urged residents and visitors to participate in requests for urine samples needed to help gauge the number of people affected. The pattern with the suspected local cases is consistent with that seen with past mosquito-borne illnesses, such as a 2013 dengue outbreak, Florida Health said. Also today, officials reported 17 new travel-related cases, raising the total to 328. It noted 4 more Zika illnesses in pregnant women, lifting the state's total to 53. http://www.cidrap.umn.edu/news-perspective/2016/07/study-notes-promising-zika-antibodies-florida-suspects-more-local-cases

Paraguay reports first cases of Zika-linked microcephalyGoogle +0 0 0 0PrintWednesday, July 27 2016Associated Press AP Photo/Fernando Vergara ASUNCION, Paraguay (AP) -- Health authorities in Paraguay are reporting the country's first two cases of babies born with the microcephaly birth defect related to the Zika virus. The virus is mainly spread by mosquitoes but cases of sexual transmission have also occurred. Some women who contract it during their pregnancies have given birth to babies with microcephaly, which leads to babies with abnormally small heads and improperly developed brains. Health Ministry official Agueda Cabello said Wednesday that the two cases of birth defects linked to Zika were confirmed in a laboratory this week. Both babies are in stable condition and are part of a group of 29 babies with microcephaly. The rest are still being tested. http://www.wbal.com/article/179352/130/paraguay-reports-first-cases-of-zika-linked-microcephaly

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Two new Zika cases have been confirmed in Delaware and state public health officials announced new transmission guidelines following the first reported case of female-to-male sexual transmission in New York. According to the Division of Public Health, a Sussex County woman and a New Castle County man tested positive for Zika, bringing Delaware's total number of cases into the double digits. http://www.wdel.com/story/76357-new-zika-info-del-has-10-cases-fla-may-have-1st-u-s-mosquito-transmission-women-pass-disease-through-sex

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Arkansas' 7th case of Zika was confirmed this week, Meg Mirivel with the Arkansas Department of Health told 40/29 News.The department is not allowed to release details on where the patient lives. The patient got Zika after traveling to the Pacific Islands, Mirivel said.All of Arkansas' Zika cases have been related to travel, she said. http://www.4029tv.com/news/7th-case-of-Zika-confirmed-in-Arkansas/40916112

At A Glance - Zika Virus in Arkansas (as of July 27, 2016)Travel-associated Zika virus disease cases reported: 7 Locally acquired cases reported: 0

Zika Confirmed Cases County Cases* Chelan1Clallam1Cowlitz 1Franklin1King6Kitsap1Mason1Pierce1Skagit1Snohomish 2Washington State Total 16* Confirmed travel-associated cases in WA as of 7/27/16

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A Franklin County man in his 30s has tested positive for the Zika virus after recent travel to Mexico. The virus is transmitted to humans by infected mosquitos, but once a person is infected, the virus can be spread through sexual contact. The type of mosquito that carries the virus does not live in the Pacific Northwest. https://www.facebook.com/Benton-Franklin-Health-District-1531167447187327/?platform=hootsuite

JULY 27, 2016 6:07 PM South Florida may have two more cases of locally acquired Zika virus This Jan. 27 photo shows samples of Aedes aegypti mosquitoes, responsible for transmitting Zika. Felipe Dana APBY DANIEL CHANG [email protected] LINKEDINGOOGLE+PINTERESTREDDITPRINTORDER REPRINT OF THIS STORY Florida health officials on Wednesday reported an additional two Zika infections that may have been spread by local mosquitoes while the number of travel-related cases rose by 17 — for a total of 381 people statewide who have contracted the virus this year. The additional cases of suspected local transmission were reported in Miami-Dade and Broward, the same South Florida counties under investigation since last week for two other cases that may be the first mosquito-borne Zika infections in the continental United States. Interactive feature: Daily Florida Zika virus trackerFlorida has now reported — but not confirmed — four cases of Zika that may have been spread by local mosquitoes. The state has the second highest number ofZika infections in the country, behind New York, including at least 53 pregnant women, who are considered to be at greatest risk from the virus because it can cause microcephaly and other birth defects. Among the 17 new Zika infections reported in Florida on Wednesday — a new record for most cases in a single day — four involved pregnant women. Health department officials said this week that they have contacted obstetricians in the Miami-Dade and Broward neighborhoods where they are investigating the suspected local cases and advising them to test their pregnant patients for Zika. Health officials also distributed Zika prevention kits containing insect repellant, bed netting, chemical tablets to kill mosquito larvae and other materials in the suspected neighborhoods. The federal Centers for Disease Control and Prevention is assisting in Florida’s investigation of the suspected local cases, identifying places where those infected may have come into contact with others, interviewing residents and collecting urine samples for testing. Health officials also are coordinating with Miami-Dade mosquito control, which sends workers to inspect the homes and nearby residences of people infected with Zika virus. Workers also conduct spraying and trap mosquitoes to be tested for Zika virus. To date, Miami-Dade and Broward have not reported any local mosquitoes testing positive for the virus. For questions about Zika, including health impacts, call the Florida health department hotline at 855-622-6735. Read more here: http://www.miamiherald.com/news/health-care/article92209207.html#storylink=cpyhttp://www.miamiherald.com/news/health-care/article92209207.html

Florida identifies two more Zika cases not related to travel05Thursday 28 July 2016 00.02 Evidence of the virus in local mosquito populations can also be used to confirm local transmissionThe Florida health department said it is investigating another two cases of Zika not related to travel to a place where the virus is being transmitted, raising the possibility of local Zika transmission in the continental United States. The Florida health department said it has identified an additional case of Zika in Miami-Dade County, where it was already investigating a possible case of Zika not related to travel, and another case in Broward County, where it has been investigating a non-travel related case. "Evidence is mounting to suggest local transmission via mosquitoes is going on in South Florida," said CDC spokesman Tom Skinner said. "These cases fit similar transmission patterns for mosquito-borne diseases such as Chikungunya that we've seen in South Florida in years past." To confirm whether Zika is being transmitted locally, epidemiologists must survey households and neighbours within a 150-yard radius around the residence of the person who has Zika, which constitutes the flying range of the mosquitoes that carry the virus. According to the US Zika response plan, Zika transmission is defined as two or more cases not due to travel or sex with an infected person that occur in a one-mile diameter over the course of a month. Evidence of the virus in local mosquito populations can also be used to confirm local transmission. Florida heath department officials said investigations intothe new cases begins today. The state is urging residents andvisitors to participate in requests for urine samples by thedepartment in the areas of investigation. These results willhelp the department determine the number of people affected. In addition to the possible cases of non-travel related transmission, Florida today reported 328 travel-related cases of Zika. The state is monitoring 53 pregnant women who had Zika infections. http://www.rte.ie/news/2016/0727/805326-zika-virus/?utm_medium=twitter&utm_source=twitterfeed

Florida officials investigating 4 possible non-travel-related Zika casesBy Debra Goldschmidt, CNN Updated 7:08 PM ET, Wed July 27, 2016 Everything you need to know about Zika 01:42Story highlightsNone of the four individuals has traveled to Zika-affected areasInvestigators are asking residents for urine samples in an effort to find more Zika cases (CNN)Health officials in Florida are now investigating four possible non-travel-related cases of Zika virus, the state Department of Health said Wednesday. Two of the four cases are in Miami-Dade County while the other two are in Broward County. None of the four individuals has traveled to Zika-affected areas. Sexual transmission has not been ruled out. First case of female-to-male Zika transmission"We are looking into other modes of transmission. We're conducting this investigation as we would other mosquito-borne viruses, such as dengue (fever)," Mara Gambineri, communications director for the Florida Department of Health, wrote in an email to CNN.Two of the four cases had been announced last week (one each in Miami-Dade and Broward counties).Officials are going door-to-door asking residents to provide urine samples and other information in an effort to determine how many people may be infected with the virus. It is possible that someone could unknowingly be infected since 80% of those infected have no symptoms.If any of these four cases is determined to be an infection transmitted by local mosquitoes, it would signify the first local mosquito transmission of Zika in the continental United States. Federal health officials have said local transmission should be expected, although they don't anticipate that it will be widespread. Zika virus: The latest you need to know"Evidence is mounting to suggest local transmission via mosquitos is going on in South Florida," Tom Skinner, senior press officer at the Centers for Disease Control and Prevention, wrote in an email. "These cases fit similar transmission patterns (of) mosquito borne diseases like chikungunya that we've seen in South Florida in years past."The CDC is assisting state and local health officials with the investigation in Florida.Join the conversationSee the latest news and share your comments with CNN Health on Facebook andTwitter. To date, there are 381 cases of the virus in Florida; 53 of them are pregnant women.As of July 20, the CDC reported 1,404 cases of the virus in the continental United States and Hawaii. None of those cases is a result of local mosquito transmission. Fifteen of those individuals were infected by sexual transmission, and there is one case of a laboratory-acquired infection. (The CDC updates its numbers weekly on Thursday.)http://www.cnn.com/2016/07/27/health/florida-zika-cases/index.html

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