niman

FIGURE. Updated interim guidance: testing and interpretation recommendations*,†, §,¶ for a pregnant woman with possible exposure to Zika virus** — United States (including U.S. territories) Abbreviations: IgM = immunoglobulin M; PRNT = plaque reduction neutralization test; rRT-PCR = real-time reverse transcription–polymerase chain reaction. * A pregnant woman is considered symptomatic if one or more signs or symptoms (acute onset of fever, rash, arthralgia, or conjunctivitis) consistent with Zika virus disease is reported. A pregnant woman is considered asymptomatic if these symptoms are NOT reported. † Testing includes Zika virus rRT-PCR on serum and urine samples, Zika virus and dengue virus IgM, and PRNT on serum samples. PRNT results that indicate recent flavivirus infection should be interpreted in the context of the currently circulating flaviviruses. Refer to the laboratory guidance for updated testing recommendations (http://www.cdc.gov/zika/laboratories/lab-guidance.html). Because of the overlap of symptoms in areas where other viral illness are endemic, evaluate for possible dengue or chikungunya virus infection. § Dengue virus IgM antibody testing is recommended only for symptomatic pregnant women. ¶ If Zika virus rRT-PCR testing is requested from laboratories without IgM antibody testing capacity or a process to forward specimens to another testing laboratory, storing of additional serum samples is recommended for IgM antibody testing in the event of an rRT-PCR negative result. ** Possible exposure to Zika virus includes travel to or residence in an area with active Zika virus transmission (http://wwwnc.cdc.gov/travel/notices/), or sex (vaginal sex (penis-to-vagina sex), anal sex (penis-to-anus sex), oral sex (mouth-to-penis sex or mouth-to-vagina sex), and the sharing of sex toys) without a barrier method to prevent infection (male or female condoms for vaginal or anal sex, male condoms for oral sex (mouth-to-penis), and male condoms cut to create a flat barrier or dental dams for oral sex (mouth-to-vagina) with a partner who traveled to, or lives in an area with active Zika virus transmission.

Updated Recommendations for Postnatal Management of Pregnant Women with Laboratory Evidence of Confirmed or Possible Zika Virus InfectionInfants born to women with laboratory evidence of confirmed or possible Zika virus infection should be evaluated for congenital Zika virus infection in accordance with CDC interim guidance for health care providers caring for infants with possible Zika virus infection (16). Zika virus testing is recommended for these infants regardless of the presence or absence of phenotypic abnormalities (14). Previous published guidance recommended that testing be performed on cord blood or infant serum; however, the use of cord blood to diagnose other congenital viral infections, such as HIV and syphilis, has sometimes yielded inaccurate results (17–20). Maternal blood can contaminate cord blood specimens leading to false-positive results, whereas Wharton’s jelly in the umbilical cord can yield false-negative results (19,20). Cord blood samples can also become clotted, which does not allow for appropriate serologic testing. Therefore, although collection and testing of cord blood for Zika virus testing can be performed, these results should be interpreted in conjunction with infant serum results. Pathology evaluation of fetal tissue specimens (e.g., placenta and umbilical cord)*** is another important diagnostic tool to establish the presence of maternal Zika virus infection and can provide a definitive diagnosis for pregnant women with Zika virus infection whose serology results indicate recent unspecified flavivirus infection. In addition, pathology findings might also be helpful in evaluating pregnant women who seek care >12 weeks after symptom onset or possible exposure; Zika virus RNA has been reported to persist in tissue specimens including placenta and fetal brain (21). A positive rRT-PCR or immunohistochemical staining on the placenta indicates the presence of maternal infection (21). Pregnant women with laboratory evidence of confirmed or possible Zika virus infection who experience a fetal loss or stillbirth should be offered pathology testing for Zika virus infection; testing includes rRT-PCR and immunohistochemical staining of fixed tissue (21). This testing might provide insight into the etiology of the fetal loss, which could inform a woman’s future pregnancy planning. Additional information is available at http://www.cdc.gov/zika. Top AcknowledgmentsAron J. Hall, Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC; Amy J. Lambert, Ronald M. Rosenberg, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; Diane Morof, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; Evelyn M. Rodriguez, Division of Global HIV/AIDS and Tuberculosis, Center for Global Health, CDC; Gail Thompson, Toby L. Merlin, Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, CDC; Heather J. Menzies, Division Of Global Health Protection, Center for Global Health, CDC; John R. Sims, Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, CDC; Angela D. Aina, Karen R. Broder, Division Of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC; Rita M. Traxler, Division Of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, CDC.

Updated Recommendations for Prenatal Management of Pregnant Women with Laboratory Evidence of Confirmed or Possible Zika Virus InfectionLaboratory evidence of a confirmed recent Zika virus infection includes 1) detection of Zika virus or Zika virus RNA or antigen in any body fluid or tissue specimen or 2) positive or equivocal Zika virus or dengue virus IgM antibody test results on serum or cerebrospinal fluid with a positive (≥10) PRNT titer for Zika virus together with a negative (<10) PRNT titer for dengue virus (8). However, given that serology test results can be difficult to interpret, particularly in persons who were previously infected with or vaccinated against flaviviruses, and because the adverse outcomes caused by Zika virus infection during pregnancy are not fully described, pregnant women with laboratory evidence of recent flavivirus infection are considered to have possible Zika virus infection and should be monitored frequently (Table). Pregnant women with confirmed or possible Zika virus infection should be managed in accordance with the updated CDC Interim Guidance (Table). In addition, pregnant women with presumptive recent Zika virus or flavivirus infection (i.e., positive or equivocal Zika virus or dengue virus IgM antibody test result that needs to be confirmed by PRNT) should also be managed in accordance with this updated guidance (Table) until final results are available. Serial fetal ultrasounds (every 3–4 weeks) should be considered to assess fetal anatomy, particularly neuroanatomy, and to monitor growth. Ultrasound findings that have been associated with congenital Zika virus syndrome include microcephaly, intracranial calcifications, ventriculomegaly, arthrogryposis, and abnormalities of the corpus callosum, cerebrum, cerebellum, and eyes (1,14). Consideration of amniocentesis should be individualized, because data about its usefulness in diagnosing congenital Zika virus infection are limited (13). The presence of Zika virus RNA in the amniotic fluid might indicate fetal infection (5,15); however, a negative result does not exclude congenital Zika virus infection (13). In addition, persistent detection of Zika virus RNA in serum has been reported during pregnancy (7). The clinical implications of prolonged detection of Zika virus RNA in serum are not known; however, repeat rRT-PCR testing has been performed in some cases (5,7).

Updated Recommendations for Evaluating and Testing of Pregnant Women with Possible Zika Virus ExposureAll pregnant women in the United States and U.S. territories should be assessed for possible Zika virus exposure at each prenatal care visit. CDC recommends that pregnant women not travel to an area with active Zika virus transmission (9,10). Pregnant women who must travel to one of these areas should strictly follow steps to prevent mosquito bites during the trip.¶¶ In addition, it is recommended that pregnant women with a sex partner who has traveled to or lives in an area with active Zika virus transmission use condoms or other barrier methods to prevent infection or abstain from sex for the duration of the pregnancy (11). Symptomatic pregnant women. Pregnant women who report signs or symptoms consistent with Zika virus disease (acute onset of fever, rash, arthralgia, conjunctivitis) should be tested for Zika virus infection (Figure). The testing recommendations for symptomatic pregnant women are the same regardless of the circumstances of possible exposure; however, the type of testing recommended varies depending on the time of evaluation relative to symptom onset. Testing of serum and urine by rRT-PCR is recommended for pregnant women who seek care <2 weeks after symptom onset. This recommendation extends the previous recommendation for testing of serum from <1 week after symptom onset to <2 weeks (Figure). A positive rRT-PCR result confirms the diagnosis of recent maternal Zika virus infection. Symptomatic pregnant women with negative rRT-PCR results should receive both Zika virus IgM and dengue virus IgM antibody testing. If Zika virus rRT-PCR testing is requested from laboratories that do not have IgM antibody testing capacity or a process to forward specimens to another testing laboratory, storing of additional serum samples is recommended for IgM antibody testing in the event of a negative rRT-PCR result (12). If either the Zika virus or dengue virus IgM antibody test yields positive or equivocal results, PRNT should be performed on the same IgM-tested sample or a subsequently collected sample to rule out false-positive results (8). Symptomatic pregnant women who seek care 2–12 weeks after symptom onset should first receive Zika virus and dengue virus IgM antibody testing (Figure). If the Zika virus IgM antibody testing yields positive or equivocal results, reflex rRT-PCR testing should be automatically performed on the same serum sample to determine whether Zika virus RNA is present. A positive rRT-PCR result confirms the diagnosis of recent maternal Zika virus infection. However, if the rRT-PCR result is negative, a positive or equivocal Zika virus IgM antibody test result should be followed by PRNT. Positive or equivocal dengue IgM antibody test results with a negative Zika virus IgM antibody test result should also be confirmed by PRNT. Interpretation of serologic results has been described (8). Asymptomatic pregnant women. Testing recommendations for asymptomatic pregnant women with possible Zika virus exposure differ based on the circumstances of possible exposure (i.e., ongoing versus limited exposure) and the elapsed interval since the last possible Zika virus exposure (Figure). Asymptomatic pregnant women living in areas without active Zika virus transmission who are evaluated <2 weeks after possible Zika virus exposure should be offered serum and urine rRT-PCR testing (Figure). A positive rRT-PCR result confirms the diagnosis of recent maternal Zika virus infection. However, because viral RNA in serum and urine declines over time and depends on multiple factors, asymptomatic pregnant women with a negative rRT-PCR result require additional testing to exclude infection. These women should return 2–12 weeks after possible Zika virus exposure for Zika virus IgM antibody testing. A positive or equivocal IgM antibody test result should be confirmed by PRNT. Asymptomatic pregnant women living in an area without active Zika virus transmission, who seek care 2–12 weeks after possible Zika virus exposure, should be offered Zika virus IgM antibody testing (Figure). If the Zika virus IgM antibody test yields positive or equivocal results, reflex rRT-PCR testing should be performed on the same sample. If the rRT-PCR result is negative, PRNT should be performed. As recommended in previous guidance (9,13), IgM antibody testing is recommended as part of routine obstetric care during the first and second trimesters for asymptomatic pregnant women who have an ongoing risk for Zika virus exposure (i.e., residence in or frequent travel to an area with active Zika virus transmission) (Figure). Reflex rRT-PCR testing is recommended for women who have a positive or equivocal Zika virus IgM antibody test results because rRT-PCR testing provides the potential for a definitive diagnosis of Zika virus infection. Negative rRT-PCR results after a positive or equivocal Zika virus IgM antibody test result should be followed by PRNT. The decision to implement testing of asymptomatic pregnant women with ongoing risk for Zika virus exposure should be made by local health officials based on information about levels of Zika virus transmission and laboratory capacity. Symptomatic and asymptomatic pregnant women who seek care >12 weeks after symptom onset or possible Zika virus exposure. For symptomatic and asymptomatic pregnant women with possible Zika virus exposure who seek care >12 weeks after symptom onset or possible exposure, IgM antibody testing might be considered. If fetal abnormalities are present, rRT-PCR testing should also be performed on maternal serum and urine. However, a negative IgM antibody test or rRT-PCR result >12 weeks after symptom onset or possible exposure does not rule out recent Zika virus infection because IgM antibody and viral RNA levels decline over time. Given the limitations of testing beyond 12 weeks after symptom onset or possible exposure, serial fetal ultrasounds should be considered.

IntroductionZika virus continues to spread worldwide, and as of July 21, 2016, 50 countries and territories reported active Zika virus transmission (locations with mosquitoes transmitting Zika virus to persons in the area).¶ Although most persons with Zika virus infection are asymptomatic or have mild clinical disease, infection during pregnancy can cause congenital microcephaly and other brain defects (1). Zika virus has also been linked to other adverse pregnancy outcomes, including miscarriage and stillbirth (1,2). The U.S. Zika Pregnancy Registry (USZPR)** and the Puerto Rico Zika Active Pregnancy Surveillance System (ZAPPS)†† were established in collaboration with state, tribal, local, and territorial health departments to monitor pregnant women with confirmed or possible Zika virus infection to determine the risk for Zika virus infection during pregnancy and the spectrum of conditions associated with congenital Zika virus infection (3). As of July 14, 2016, a total of 400 women in the 50 U.S. states and the District of Columbia, and 378 women in all U.S. territories (aggregated territories’ data from the USZPR and ZAPSS) were determined to have laboratory evidence of confirmed or possible Zika virus infection during pregnancy.§§ Data from the USZPR and published case reports indicate that Zika virus RNA can persist in serum of some pregnant women longer than had been previously reported; the longest documented duration of Zika virus RNA detection in serum is 10 weeks after symptom onset (4–7). In addition, recent data indicate that Zika virus RNA might be detected in the serum or urine of some asymptomatic pregnant women (7). The frequency of this finding is unknown, but the detection of Zika virus RNA in serum or urine provides a definitive diagnosis of Zika virus infection. Preliminary data suggest that plaque reduction neutralization testing (PRNT) might not discriminate between Zika virus and other flavivirus infections, particularly in persons with previous flavivirus exposure (8), which complicates interpretation of serologic testing (IgM antibody test and PRNT). Given these challenges, expanded rRT-PCR testing might provide a definitive diagnosis for more pregnant women who are infected with Zika virus. CDC has revised its interim guidance for U.S. health care providers caring for pregnant women with possible Zika virus exposure. The revised testing recommendations extend the timeframe for rRT-PCR testing of serum and include rRT-PCR testing for some asymptomatic pregnant women. CDC continues to evaluate all available evidence and will update recommendations as new information becomes available.

CDC has updated its interim guidance for U.S. health care providers caring for pregnant women with possible Zika virus exposure, to include the emerging data indicating that Zika virus RNA can be detected for prolonged periods in some pregnant women. To increase the proportion of pregnant women with Zika virus infection who receive a definitive diagnosis, CDC recommends expanding real-time reverse transcription–polymerase chain reaction (rRT-PCR) testing. Possible exposures to Zika virus include travel to or residence in an area with active Zika virus transmission, or sex* with a partner who has traveled to or resides in an area with active Zika virus transmission without using condoms or other barrier methods to prevent infection.† Testing recommendations for pregnant women with possible Zika virus exposure who report clinical illness consistent with Zika virus disease§ (symptomatic pregnant women) are the same, regardless of their level of exposure (i.e., women with ongoing risk for possible exposure, including residence in or frequent travel to an area with active Zika virus transmission, as well as women living in areas without Zika virus transmission who travel to an area with active Zika virus transmission, or have unprotected sex with a partner who traveled to or resides in an area with active Zika virus transmission). Symptomatic pregnant women who are evaluated <2 weeks after symptom onset should receive serum and urine Zika virus rRT-PCR testing. Symptomatic pregnant women who are evaluated 2–12 weeks after symptom onset should first receive a Zika virus immunoglobulin (IgM) antibody test; if the IgM antibody test result is positive or equivocal, serum and urine rRT-PCR testing should be performed. Testing recommendations for pregnant women with possible Zika virus exposure who do not report clinical illness consistent with Zika virus disease (asymptomatic pregnant women) differ based on the circumstances of possible exposure. For asymptomatic pregnant women who live in areas without active Zika virus transmission and who are evaluated <2 weeks after last possible exposure, rRT-PCR testing should be performed. If the rRT-PCR result is negative, a Zika virus IgM antibody test should be performed 2–12 weeks after the exposure. Asymptomatic pregnant women who do not live in an area with active Zika virus transmission, who are first evaluated 2–12 weeks after their last possible exposure should first receive a Zika virus IgM antibody test; if the IgM antibody test result is positive or equivocal, serum and urine rRT-PCR should be performed. Asymptomatic pregnant women with ongoing risk for exposure to Zika virus should receive Zika virus IgM antibody testing as part of routine obstetric care during the first and second trimesters; immediate rRT-PCR testing should be performed when IgM antibody test results are positive or equivocal. This guidance also provides updated recommendations for the clinical management of pregnant women with confirmed or possible Zika virus infection. These recommendations will be updated when additional data become available.

Titilope Oduyebo, MD1; Irogue Igbinosa, MD2; Emily E. Petersen, MD1; Kara N.D. Polen, MPH2; Satish K. Pillai, MD3; Elizabeth C. Ailes, PhD2; Julie M. Villanueva, PhD3; Kim Newsome, MPH2; Marc Fischer, MD4; Priya M. Gupta, MPH5; Ann M. Powers, PhD4; Margaret Lampe, MPH6; Susan Hills, MBBS4; Kathryn E. Arnold, MD2; Laura E. Rose, MTS3; Carrie K. Shapiro-Mendoza, PhD1; Charles B. Beard, PhD4; Jorge L. Muñoz, PhD4; Carol Y. Rao, ScD7; Dana Meaney-Delman, MD8; Denise J. Jamieson, MD1; Margaret A. Honein, PhD2 Corresponding author: Titilope Oduyebo, 770-488-7100, [email protected]. Top 1Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; 2Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, CDC; 3Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 4Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 5Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, CDC;6Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; 7Division Of Global Health Protection, Center for Global Health, CDC; 8Office of the Director, National Center for Emerging and Zoonotic Infectious Diseases, CDC.

Update: Interim Guidance for Health Care Providers Caring for Pregnant Women with Possible Zika Virus Exposure — United States, July 2016Early Release / July 25, 2016 / 65 http://www.cdc.gov/mmwr/volumes/65/wr/mm6529e1.htm?s_cid=mm6529e1_w

ReferencesRasmussen 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 PubMedOster AM, Russell K, Stryker JE, et al. Update: interim guidance for prevention of sexual transmission of Zika virus—United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:323–5. CrossRef PubMedWorld Health Organization. Prevention of sexual transmission of Zika virus: interim guidance update. June 7, 2016. Geneva, Switzerland: World Health Organization; 2016. http://apps.who.int/iris/bitstream/10665/204421/1/WHO_ZIKV_MOC_16.1_eng.pdf?ua=1Turmel JM, Abgueguen P, Hubert B, et al. Late sexual transmission of Zika virus related to persistence in the semen. Lancet 2016;387:2501. CrossRefPubMedMansuy J, Pasquier C, Daudin M, et al. Zika virus in semen of a patient returning from a non-epidemic area. Lancet Infect Dis 2016;16:894–5.CrossRefFréour 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(23). PubMedDavidson A, Slavinski S, Komoto K, Rakeman J, Weiss D. Suspected female-to-male sexual transmission of Zika virus—New York City, 2016. MMWR Morb Mortal Wkly Rep 2016;65:716–7. CrossRef PubMedPrisant N, Bujan L, Benichou H, et al. Zika virus in the female genital tract. Lancet Infect Dis 2016. Epub July 11, 2016. CrossRefPetersen EE, Polen KN, Meaney-Delman D, et al. Update: interim guidance for health care providers caring for women of reproductive age with possible Zika virus exposure—United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:315–22. PubMedOduyebo T, Igbinosa I, Petersen EE, et al. Update: interim guidance for health care providers caring for pregnant women with possible Zika virus exposure—United States, July 2016. MMWR Morb Mortal Wkly Rep 2016. Epub July 25, 2016.Duffy 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. CrossRefPubMedCDC. Reproductive health: contraception. Atlanta GA: US Department of Health and Human Services, CDC; 2016.http://www.cdc.gov/reproductivehealth/unintendedpregnancy/contraception.htm Top * http://www.cdc.gov/zika/geo/index.html. † Barrier methods to protect against infection include male or female condoms for vaginal or anal sex, male condoms for oral sex (mouth-to-penis), and male condoms cut to create a flat barrier or dental dams for oral sex (mouth-to-vagina). § For the purpose of these guidelines, sex is specifically defined as vaginal sex (penis-to vagina sex), anal sex (penis-to-anus sex), oral sex (mouth-to-penis sex or mouth-to-vagina sex), and the sharing of sex toys. ¶ http://www.cdc.gov/zika/geo/united-states.html. ** Clinical illness consistent with Zika virus disease includes one or more of the following signs or symptoms: acute onset of fever, maculopapular rash, arthralgia, or conjunctivitis. †† http://www.cdc.gov/zika/prevention. §§ http://www.cdc.gov/zika/hc-providers/diagnostic.html.

BOX. Recommendations for prevention of sexual transmission of Zika virus for couples in which one or both partners have traveled to or reside in an area with active Zika virus transmissionCouples in which a woman is pregnantCouples in which a woman is pregnant should use barrier methods against infection consistently and correctly or abstain from sex for the duration of the pregnancy. Couples who are not pregnant and are not planning to become pregnant*Couples in which a partner had confirmed Zika virus infection or clinical illness consistent with Zika virus disease should consider using barrier methods against infection consistently and correctly or abstain from sex as follows: ― Men with Zika virus infection for at least 6 months after onset of illness; ― Women with Zika virus infection for at least 8 weeks after onset of illness.Couples in areas without active Zika transmission in which one partner traveled to or resides in an area with active Zika virus transmission but did not develop symptoms of Zika virus disease should consider using barrier methods against infection or abstaining from sex for at least 8 weeks after that partner departed the Zika-affected area. Couples who reside in an area with active Zika virus transmission might consider using barrier methods against infection or abstaining from sex while active transmission persists. * Couples who do not desire pregnancy should use the most effective contraceptive methods that can be used correctly and consistently in addition to barrier methods to protect against infections, such as condoms, which reduce the risk for both sexual transmission of Zika and other sexually transmitted infections. Couples planning conception might have multiple factors to consider, which are discussed in more detail in the following: Petersen EE, Polen KN, Meaney-Delman D, et al. Update: interim guidance for health care providers caring for women of reproductive age with possible Zika virus exposure—United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:315–22.

Zika Virus Testing and Sexual TransmissionAt present, Zika virus testing for the assessment of risk for sexual transmission is of uncertain value, because current understanding of the duration and pattern of shedding of Zika virus in the male and female genitourinary tract is limited. Therefore, testing of specimens to assess risk for sexual transmission is currently not recommended. Zika virus testing is recommended for persons who have had possible sexual exposure to Zika virus and who develop signs or symptoms consistent with Zika virus disease.§§ All pregnant women should be tested if they have had possible exposure to Zika virus, including sexual exposure (9,10). CDC urges health care providers to report to local and state health departments all cases of Zika virus disease, including those suspected to have occurred by sexual transmission.

Updated RecommendationsRecommendations for pregnant couples. Zika virus infection is of particular concern during pregnancy. Pregnant women with sex partners (male or female) who live in or who have traveled to an area with active Zika virus transmission should consistently and correctly use barriers against infection during sex or abstain from sex for the duration of the pregnancy. These recommendations reduce the risk for sexual transmission of Zika virus during pregnancy, which could have adverse fetal effects. Pregnant women should discuss with their health care provider their own and their sex partner’s history of having been in areas with active Zika virus transmission and history of illness consistent with Zika virus disease**; providers can consult CDC’s guidance for evaluation and testing of pregnant women (10). Recommendations for couples who are not pregnant and are not planning to become pregnant. Several factors could influence a couple’s level of concern about sexual transmission of Zika virus. The risk for acquiring mosquito-borne Zika virus infection in areas with active transmission depends on the duration and extent of exposure to infected mosquitoes and the steps taken to prevent mosquito bites.†† According to currently available information, most Zika virus infections appear to be 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 (11). Men and women who want to reduce the risk for sexual transmission of Zika virus should use barrier methods against infection consistently and correctly during sex or abstain from sex when one sex partner has traveled to or lives in an area with active Zika virus transmission. Based on expert opinion and on limited but evolving information about the sexual transmission of Zika virus, the recommended duration of consistent use of a barrier method against infection or abstinence from sex depends on whether the sex partner has confirmed infection or clinical illness consistent with Zika virus disease and whether the sex partner is male or female (Box). The rationale for these time frames has been published previously (9). Couples who do not desire pregnancy should use available strategies to prevent unintended pregnancy and might consider multiple options, including (in addition to condoms, the only method that protects against both pregnancy and sexual transmission of Zika virus) use of the most effective contraceptive methods that can be used correctly and consistently (9,12). In addition, couples should be advised that correct and consistent use of barrier methods against infection, such as condoms, reduces the risk for other sexually transmitted infections.

Zika virus has been identified as a cause of congenital microcephaly and other serious brain defects (1). CDC issued interim guidance for the prevention of sexual transmission of Zika virus on February 5, 2016, with an initial update on April 1, 2016 (2). The following recommendations apply to all men and women who have traveled to or reside in areas with active Zika virus transmission* and their sex partners. The recommendations in this report replace those previously issued and are now updated to reduce the risk for sexual transmission of Zika virus from both men and women to their sex partners. This guidance defines potential sexual exposure to Zika virus as having had sex with a person who has traveled to or lives in an area with active Zika virus transmission when the sexual contact did not include a barrier to protect against infection. Such barriers include male or female condoms for vaginal or anal sex and other barriers for oral sex.† Sexual exposure includes vaginal sex, anal sex, oral sex, or other activities that might expose a sex partner to genital secretions.§ This guidance will be updated as more information becomes available. As of July 20, 2016, 15 cases of Zika virus infection transmitted by sexual contact had been reported in the United States.¶ Sexually transmitted Zika virus infection has also been reported in other countries (3). In published reports, the longest interval after symptom onset that sexual transmission from a man might have occurred was 32–41 days (4). Using real-time reverse transcription–polymerase chain reaction (rRT-PCR), which detects viral RNA but is not necessarily a measure of infectivity, Zika virus RNA has been detected in semen up to 93 days after symptom onset (5). In addition, one report describes an asymptomatically infected man with Zika virus RNA detected by rRT-PCR in his semen 39 days following departure from a Zika virus-affected area and who might have sexually transmitted Zika virus to his partner (6). In most cases, serial semen specimens were not collected until Zika virus RNA was no longer detectable so that the precise duration and pattern of infectious Zika virus in semen remain unknown. Zika virus also has been transmitted from a symptomatically infected woman to a male sex partner (7), and Zika virus RNA has been detected in vaginal fluids 3 days after symptom onset and in cervical mucus up to 11 days after symptom onset (8). For sex partners of infected women, Zika virus might be transmitted through exposure to vaginal secretions or menstrual blood. Sexual transmission of infections, including those caused by other viruses, is reduced by consistent and correct use of barriers to protect against infection. With this update, CDC is expanding its existing recommendations to cover all pregnant couples, which includes pregnant women with female sex partners. This guidance also describes what other couples (those who are not pregnant or planning to become pregnant) can do to reduce the risk for Zika virus transmission. CDC’s recommendations for couples planning to become pregnant have been published separately (9).

John T. Brooks, MD1; Allison Friedman, MS2; Rachel E. Kachur, MPH2; Michael LaFlam1; Philip J. Peters, MD2; Denise J. Jamieson, MD3 Corresponding author: John T. Brooks, [email protected], 404-639-3894. Top 1Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; 2Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; 3Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Update: Interim Guidance for Prevention of Sexual Transmission of Zika Virus — United States, July 2016Early Release / July 25, 2016 / 65 http://www.cdc.gov/mmwr/volumes/65/wr/mm6529e2.htm?s_cid=mm6529e2_w

Map Update https://www.google.com/maps/d/edit?hl=en&hl=en&authuser=0&authuser=0&mid=1FlIB7hHnVgGD9TlbSx5HwAj-PEQ

July 25, 2016 DEPARTMENT OF HEALTH DAILY ZIKA UPDATE: FIVE NEW TRAVEL-RELATED CASES http://www.floridahealth.gov/newsroom/2016/07/072516-zika-update.htmlContact:Communications [email protected](850) 245-4111 Tallahassee, Fla.—In an effort to keep Florida residents and visitors safe and aware about the status of the Zika virus, the Florida Department of Health will issue a Zika virus update each week day at 2 p.m. Updates will include a CDC-confirmed Zika case count by county and information to better keep Floridians prepared. There are five new travel-related cases with two in Miami-Dade, one in Okaloosa, one in Orange and one involving a pregnant women. According to CDC, symptoms associated with the Zika virus last between seven to 10 days. The department’s investigations into the possible non-travel related Zika virus cases in Miami-Dade and Broward counties are ongoing and the department will share more details as they become available. This weekend, the department worked with Dr. Marc Fischer, medical epidemiologist with CDC to develop the survey model for the expanding investigation. Today, review of the methodology and appropriate training is occurring at both DOH-Broward and DOH-Miami-Dade. Residents and visitors are urged to participate in requests for urine samples by the department in the areas of investigation. These results will help the department determine the number of people affected. Zika prevention kits and repellent are being distributed in the areas of investigation, through local OBGYN offices and at both DOH-Broward and DOH-Miami-Dade. CDC recommends that women who are pregnant or thinking of becoming pregnant postpone travel to Zika affected areas. According to CDC guidance, providers should consider testing all pregnant women with a history of travel to a Zika affected area for the virus. CDC recommends that a pregnant woman with a history of Zika virus and her provider should consider additional ultrasounds. Florida has been monitoring pregnant women with evidence of Zika regardless of symptoms since January. The total number of pregnant women who have been monitored is 47, with 15 having met the previous CDC case definition. The Council of State and Territorial Epidemiologists and CDC released a new case definition for Zika that now includes reporting both asymptomatic and symptomatic cases of Zika. Prior to this change, states reported only symptomatic non-pregnant cases and pregnant cases regardless of symptoms. This change comes as a result of increased availability for testing in commercial laboratories. County Number of Cases (all travel related) Alachua 5 Brevard 6 Broward 51 Charlotte 1 Citrus 2 Clay 3 Collier 4 Duval 6 Escambia 1 Highlands 1 Hillsborough 9 Lake 1 Lee 6 Manatee 1 Martin 1 Miami-Dade 95 Okaloosa 2 Okeechobee 1 Orange 37 Osceola 17 Palm Beach 15 Pasco 6 Pinellas 7 Polk 11 Santa Rosa 1 Seminole 11 St. Johns 3 St. Lucie 1 Volusia 5 Total cases not involving pregnant women 310 Cases involving pregnant women regardless of symptoms* 48 *Counties of pregnant women will not be shared. On Feb. 12, Governor Scott directed the State Surgeon General to activate a Zika Virus Information Hotline for current Florida residents and visitors, as well as anyone planning on traveling to Florida in the near future. The hotline, managed by the Department of Health, has assisted 2,364 callers since it launched. The number for the Zika Virus Information Hotline is 1-855-622-6735. All cases are travel-associated. There have been no locally-acquired cases of Zika in Florida. For more information on the Zika virus, click here. The department urges Floridians to drain standing water weekly, no matter how seemingly small. A couple drops of water in a bottle cap can be a breeding location for mosquitoes. Residents and visitors also need to use repellents when enjoying the Florida outdoors. More Information on DOH action on Zika: On Feb. 3, Governor Scott directed the State Surgeon General to issue a Declaration of Public Health Emergency for the counties of residents with travel-associated cases of Zika.There have been 29 counties included in the declaration– Alachua, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Highlands, Hillsborough, Lake, Lee, Manatee, Martin, Miami-Dade, Okaloosa, Okeechobee, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Santa Rosa, Seminole, St. Johns, St. Lucie and Volusia – and will be updated as needed.DOH encourages Florida residents and visitors to protect themselves from all mosquito-borne illnesses by draining standing water; covering their skin with repellent and clothing; and covering windows with screens.DOH has a robust mosquito-borne illness surveillance system and is working with CDC, the Florida Department of Agriculture and Consumer Services and local county mosquito control boards to ensure that the proper precautions are being taken to protect Florida residents and visitors.On April 6, Governor Scott and Interim State Surgeon General Dr. Celeste Philip hosted a conference call with Florida Mosquito Control Districts to discuss ongoing preparations to fight the possible spread of the Zika virus in Florida. There were 74 attendees on the call.On May 11, Governor Scott met with federal leaders on the importance of preparing for Zika as we would a hurricane. Governor Scott requested 5,000 Zika preparedness kits from HHS Secretary Sylvia Burwell as well as a plan from FEMA on how resources will be allocated to states in the event an emergency is declared.On June 1, Governor Scott requested for President Obama to provide preparedness items needed in order to increase Florida’s capacity to be ready when Zika becomes mosquito-borne in our state.On June 9, Governor Scott spoke with Health and Human Services Secretary Sylvia Burwell and CDC Director Dr. Tom Frieden on Zika preparedness and reiterated the requests that he has continued to make to the federal government to prepare for the Zika virus once it becomes mosquito-borne in Florida. Governor Scott also requested that the CDC provide an additional 1,300 Zika antibody tests to Florida to allow individuals, especially pregnant women and new mothers, to see if they ever had the Zika virus.On June 23, Governor Scott announced that he will use his emergency executive authority to allocate $26.2 million in state funds for Zika preparedness, prevention and response in Florida.On June 28, the department announced the first confirmed case of microcephaly in an infant born in Florida whose mother had a travel-related case of Zika. The mother of the infant contracted Zika while in Haiti. Following the confirmation of this case, Governor Scott called on CDC to host a call with Florida medical professionals, including OBGYNs and physicians specializing in family medicine, to discuss the neurological impacts of Zika and what precautions new and expecting mothers should take.On July 1, CDC hosted a call with Florida medical professionals, including OBGYNs, pediatricians and physicians specializing in family medicine, to discuss the neurological impacts of Zika and what precautions new and expecting mothers should take. More than 120 clinicians participated.Florida currently has the capacity to test 4,783 people for active Zika virus and 2,170 for Zika antibodies.Federal Guidance on Zika: According to CDC, Zika illness is generally mild with a rash, fever and joint pain. CDC researchers have concluded that Zika virus is a cause of microcephaly and other birth defects.The FDA released guidance regarding donor screening, deferral and product management to reduce the risk of transfusion-transmission of Zika virus. Additional information is available on the FDA website here.CDC has put out guidance related to the sexual transmission of the Zika virus. This includes CDC recommendation that if you have traveled to a country with local transmission of Zika you should abstain from unprotected sex.For more information on Zika virus, click here. About the Florida Department of Health The department, nationally accredited by the Public Health Accreditation Board, works to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts. Follow us on Twitter at @HealthyFla and on Facebook. For more information about the Florida Department of Health, please visit www.FloridaHealth.gov.

County Number of Cases (all travel related) Alachua 5 Brevard 6 Broward 51 Charlotte 1 Citrus 2 Clay 3 Collier 4 Duval 6 Escambia 1 Highlands 1 Hillsborough 9 Lake 1 Lee 6 Manatee 1 Martin 1 Miami-Dade 95 Okaloosa 2 Okeechobee 1 Orange 37 Osceola 17 Palm Beach 15 Pasco 6 Pinellas 7 Polk 11 Santa Rosa 1 Seminole 11 St. Johns 3 St. Lucie 1 Volusia 5 Total cases not involving pregnant women 310 Cases involving pregnant women regardless of symptoms* 48 *Counties of pregnant women will not be shared.

Map Update https://www.google.com/maps/d/edit?hl=en&hl=en&authuser=0&authuser=0&mid=1FlIB7hHnVgGD9TlbSx5HwAj-PEQ

Pennsylvania Blood Tests Submitted for Zika TestingInformation updated Mondays at 2 p.m. Confirmed Infections: 51Pending Test Results: 249Last update: 07/25/2016 http://www.health.pa.gov/My Health/Diseases and Conditions/U-Z/Zikavirus/Pages/ZikaVirusHomePage.aspx#.V5ZbQ7grLFi

Pennsylvania Blood Tests Submitted for Zika TestingInformation updated Mondays at 2 p.m. Confirmed Infections: 51Pending Test Results: 249Last update: 07/25/2016

Brazil asks whether Zika acts alone to cause birth defectsPuzzling distribution of cases suggests Zika is not the only factor in reported microcephaly surge. Declan Butler25 July 2016Article toolsRights & PermissionsFelipe Dana/AP A health worker sprays insecticide to combat the mosquito that spreads Zika virus, in Paraíba state, Brazil. Researchers at Brazil’s ministry of health have launched a study to explore why the country has a peculiar distribution of Zika-linked microcephaly cases — babies born with abnormally small heads. Zika virus has spread throughout Brazil, but extremely high rates of microcephaly have been reported only in the country's northeast. Although evidence suggests that Zika can cause microcephaly, the clustering pattern hints that other environmental, socio-economic or biological factors could be at play. “We suspect that something more than Zika virus is causing the high intensity and severity of cases,” says Fatima Marinho, director of information and health analysis at the ministry. If that turns out to be true, it could change researchers' assessment of the risk that Zika poses to pregnant women and their children. Related storiesZika raises profile of more common birth-defect virusZika must remain a high priorityZika and birth defects: what we know and what we don’tMore related stories The idea has long been on Brazilian researchers' radar. "This is being discussed in almost every scientific meeting," says Lavinia Schüler-Faccini, a researcher at the Federal University of Rio Grande do Sul. But the new inquiry marks the first time that scientists at the health ministry have taken up the hypothesis. The ministry has asked Oliver Brady, an epidemiologist at the London School of Hygiene & Tropical Medicine, and Simon Hay, director of geospatial science at the Institute for Health Metrics and Evaluation in Seattle, Washington, to assist the collaboration, along with researchers in Brazil. “The aim is to understand why we are only observing elevated rates in the northeast,” says Brady, who flew into Brasília this month to begin work. "I think they may be on to something," says Linda Birnbaum, director of the US National Institute of Environmental Health Sciences (NIEHS). Zika was discovered in 1947 and hadn’t been implicated in birth defects until now; and current strains of the virus don’t show any significant mutations that might have increased its virulence. "So why now?" she asks. Surprising clustersThe northeast was where the first reported surge in microcephaly cases in Brazil began a year ago. Health officials had expected that they would later see the same high rates in other parts of the country. "We were expecting an explosion of birth defects," says Marinho. But as of 20 July, almost 90% of the 1,709 confirmed cases of congenital microcephaly or birth defects of the central nervous system that have been reported in Brazil since last November are in a relatively small area: in the coastal hinterland of the northeastern tip. The affected area is about the size of the United Kingdom, whereas Brazil is almost as large as the United States. What's particularly surprising, says Marinho, is that just three cases have been confirmed in Brazil’s second-most populous state, Minas Gerais, which borders the most-affected part of the northeast region. Poor data on the scale and timing of Zika outbreaks across Brazil make it difficult to tell whether large increases in microcephaly elsewhere may simply have been delayed — but ministry scientists now think that the northeast represents a marked outlier, she says. Other factors at play?There are many hypotheses about what might be going on. Marinho says that her team's data, submitted for publication, hint that socio-economic factors might be involved. The majority of women who have had babies with microcephaly have, for example, been young, single, black, poor and tend to live in small cities or on the outskirts of big ones, she says. Another idea is that co-infections of Zika and other viruses, such as dengue and chikungunya, might be interacting to cause the high intensity of birth defects in the area. A third possibility was put forward in a paper published last month1, in which researchers from Brazilian labs noted a correlation between low vaccination rates for yellow fever and the microcephaly clusters. Because yellow fever and Zika are in the same virus family — they are both flaviviruses — the scientists speculated that the vaccine might provide some protection against Zika. "It is a plausible hypothesis," says Duane Gubler, who studies mosquito-borne diseases at Duke–NUS Medical School in Singapore. Marinho, however, is sceptical — arguing that there are many areas with low yellow fever vaccination rates that haven't had many confirmed microcephaly cases. The Brazilian doctor who was the first to report a firm link between Zika and microcephaly — Adriana Melo at IPESQ, a research institute in Campina Grande — is also among those who have suggested that other factors could be involved. In a preprint posted on the bioRxiv server on 15 July2, Melo and her colleagues at the Federal University of Rio de Janeiro reported that they had found bovine viral diarrhoea virus (BVDV) proteins in the brains of three fetuses with microcephaly from Paraíba state. The brains tested positive for Zika RNA, but the researchers found no Zika proteins. BVDV causes serious birth defects in cattle but is not known to infect people. Melo's team suggest that Zika infection might reduce physiological barriers, making it easier for BVDV to cause infections. But they haven't ruled out the possibility, raised by other researchers, that their findings might be due to contamination (BVDV is a common contaminant of fetal bovine serum and other bovine-derived lab reagents). Patchy dataThe Brazilian health ministry’s study will test for BVDV among other hypotheses, says Brady. Researchers will re-analyse raw data on microcephaly cases, and will model connections with possible co-factors such as socio-economic status, water contamination, and mosquito-borne diseases. Most of this information will come from health ministry databases, but the team will also study experimental data, such as how people's immune response may change after past infection with other viruses such as dengue. But researchers say that the information they have may not be enough to pin down whether factors in addition to Zika are involved. Much of the microcephaly raw data comes from routine hospital reports, which are often incomplete. And lab tests to confirm Zika infection are rarely carried out. Ultimately, researchers and public-health officials might have to wait for higher-quality data from research programmes such as the Zika in Infants and Pregnancy Study, which launched last month in Puerto Rico and aims to monitor as many as 10,000 pregnant women. The US National Institutes of Health (including Birnbaum’s NIEHS) and the Oswaldo Cruz Foundation in Brazil are doing the work, which will also include testing whether nutritional, socio-economic and environmental factors have a role. The study will expand to Brazil, Colombia and other Zika-affected areas. Until more is known about Zika and the causes of increased microcephaly rates in Brazil’s northeast, public-health actions and advice must err on the side of precaution, says Ian Lipkin, a virologist and outbreak specialist at Columbia University in New York. Nature doi:10.1038/nature.2016.20309ReferencesDe Goes Cavalcanti, L. P. et al. J. Infect. Dev. Countries 10, 563–566 (2016). Show contextNogueira, F. C. S., Velasquez, E., Melo, A. S. O. & Domont, G. B. Preprint at bioRxivhttp://dx.doi.org/10.1101/062596 (2016). Hide context…In a preprint posted on the bioRxiv server on 15 July2, Melo and her colleagues at the Federal University of Rio de Janeiro reported that they had found bovine viral diarrhoea virus (BVDV) proteins in the brains of three fetuses with microcephaly from Paraíba state… in article

Researchers at Brazil’s ministry of health have launched a study to explore why the country has a peculiar distribution of Zika-linked microcephaly cases — babies born with abnormally small heads. Zika virus has spread throughout Brazil, but extremely high rates of microcephaly have been reported only in the country's northeast. Although evidence suggests that Zika can cause microcephaly, the clustering pattern hints that other environmental, socio-economic or biological factors could be at play. http://www.nature.com/news/brazil-asks-whether-zika-acts-alone-to-cause-birth-defects-1.20309

weekconfdiscarduntestedtotalweekly increase28218019629741272175160256622618641121941325135611218117241151102164272365081137192264369118232164148957205265788719526508191852443721417521325881642026506154182244111421516330