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CDPH Weekly Update on Number of Zika Virus Infections in California July 15, 2016 The following table provides the number of travel-associated infections with Zika virus in California residents in 2015 and 2016. CDPH is following CDC testing guidelines. This table is updated every Friday. As of July 15, 2016, there have been 86 travel-associated Zika virus infections in California.  Total infections: 86  Cumulative number of infections in pregnant women: 19*  Cumulative number of infections due to sexual transmission: 1 Zika virus infections in California, 2015-2016§ (as of July 15, 2016) County Travel-associated ¥ Locally acquired † Alameda 5 0 Contra Costa 4 0 Fresno 1 0 Los Angeles 22 0 Marin 1 0 Merced 2 0 Napa 1 0 Orange 8 0 Riverside 1 0 San Bernardino 5 0 San Diego 16** 0 San Francisco 5 0 San Joaquin 3 0 San Mateo 2 0 Santa Clara 4 0 Solano 1 0 Sonoma 1 0 Stanislaus 1 0 Yolo 2 0 Yuba 1 0 Total 86 0 *Local Health Departments and CDPH are monitoring all pregnant women and their infants §Total number includes laboratory-confirmed and probable infections as defined by the CSTE Position Statement ¥Persons exposed through travel to an affected area or contact with a traveler https://www.cdph.ca.gov/HealthInfo/discond/Documents/TravelAssociatedCasesofZikaVirusinCA.pdf

ReferencesLanciotti RS, Kosoy OL, Laven JJ, et al. Genetic and serologic properties of Zika virus associated with an epidemic, Yap State, Micronesia, 2007. Emerg Infect Dis 2008;14:1232–9. CrossRef PubMedCDC. Zika MAC-ELISA: instructions for use. Atlanta, GA: US Department of Health and Human Services, CDC; 2016.http://www.fda.gov/downloads/MedicalDevices/Safety/EmergencySituations/UCM488044.pdfDudley DM, Aliota MT, Mohr EL, et al. A rhesus macaque model of Asian-lineage Zika virus infection. Nat Commun 2016;7:12204. CrossRefPubMedPrisant N, Bujan L, Benichou H, et al. Zika virus in the female genital tract [Letter]. Lancet Infect Dis 2016. E-pub July 11, 20162016. CrossRefOster 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 PubMedHills SL, Russell K, Hennessey M, et al. Transmission of Zika virus through sexual contact with travelers to areas of ongoing transmission—continental United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:215–6. CrossRef PubMed Top Suggested citation for this article: Davidson 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. ePub: 15 July 2016. DOI: http://dx.doi.org/10.15585/mmwr.mm6528e2.

A routine investigation by the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) identified a nonpregnant woman in her twenties who reported she had engaged in a single event of condomless vaginal intercourse with a male partner the day she returned to NYC (day 0) from travel to an area with ongoing Zika virus transmission. She had headache and abdominal cramping while in the airport awaiting return to NYC. The following day (day 1) she developed fever, fatigue, a maculopapular rash, myalgia, arthralgia, back pain, swelling of the extremities, and numbness and tingling in her hands and feet. In addition, on day 1, the woman began menses that she described as heavier than usual. On day 3 she visited her primary care provider who obtained blood and urine specimens. Zika virus RNA was detected in both serum and urine by real-time reverse transcription–polymerase chain reaction (rRT-PCR) performed at the DOHMH Public Health Laboratory using a test based on an assay developed at CDC (1). The results of serum testing for anti-Zika virus immunoglobulin M (IgM) antibody performed by the New York State Department of Health Wadsworth Center laboratory was negative using the CDC Zika IgM antibody capture enzyme-linked immunosorbent assay (Zika MAC-ELISA) (2). Seven days after sexual intercourse (day 6), the woman’s male partner, also in his twenties, developed fever, a maculopapular rash, joint pain, and conjunctivitis. On day 9, three days after the onset of his symptoms, the man sought care from the same primary care provider who had diagnosed Zika virus infection in his female partner. The provider suspected sexual transmission of Zika virus and contacted DOHMH to seek testing for the male partner. That same day, day 9, urine and serum specimens were collected from the man. Zika virus RNA was detected in urine but not serum by rRT-PCR testing at the DOHMH Public Health Laboratory. Zika virus IgM antibodies were not detectable by the CDC Zika MAC-ELISA assay performed at the New York State Department of Health Wadsworth Center. The CDC Arbovirus Disease Branch confirmed all rRT-PCR results for urine and serum specimens from both partners. During an interview with DOHMH on day 17, the man confirmed that he had not traveled outside the United States during the year before his illness. He also confirmed a single encounter of condomless vaginal intercourse with his female partner (the patient) after her return to NYC and reported that he did not engage in oral or anal intercourse with her. The man reported that he noticed no blood on his uncircumcised penis immediately after intercourse that could have been associated either with vaginal bleeding or with any open lesions on his genitals. He also reported that he did not have any other recent sexual partners or receive a mosquito bite within the week preceding his illness. Independent follow-up interviews with the woman and man corroborated the exposure and illness history. The patients were consistent in describing illness onset, symptoms, sexual history, and the woman’s travel. This information also was consistent with the initial report from the primary care provider. The timing and sequence of events support female-to-male Zika virus transmission through condomless vaginal intercourse. The woman likely was viremic at the time of sexual intercourse because her serum, collected 3 days later, had evidence of Zika virus RNA by rRT-PCR. Virus present in either vaginal fluids or menstrual blood might have been transmitted during exposure to her male partner’s urethral mucosa or undetected abrasions on his penis. Recent reports document detection of Zika virus in the female genital tract, including vaginal fluid. A study on nonhuman primates found Zika virus RNA detected in the vaginal fluid of three nonpregnant females up to 7 days after subcutaneous inoculation (3), and Zika virus RNA was detected in specimens from a woman’s cervical mucous, genital swab, and endocervical swab collected 3 days after illness onset, using an unspecified RT-PCR test (4). Further studies are needed to determine the characteristics of Zika virus shedding in the genital tract and vaginal fluid of humans. This case represents the first reported occurrence of female-to-male sexual transmission of Zika virus. Current guidance to prevent sexual transmission of Zika virus is based on the assumption that transmission occurs from a male partner to a receptive partner (5,6). Ongoing surveillance is needed to determine the risk for transmission of Zika virus infection from a female to her sexual partners. Providers should report to their local or state health department any patients with illnesses compatible with Zika virus disease who do not have a history of travel to an area with ongoing Zika virus transmission, but who had a sexual exposure to a partner who did travel. Persons who want to reduce the risk for sexual transmission of Zika virus should abstain from sex or correctly and consistently use condoms for vaginal, anal, and oral sex, as recommended in the current CDC guidance (5). Guidance on prevention of sexual transmission of Zika virus, including other methods of barrier protection, will be updated as additional information becomes available (http://www.cdc.gov/zika).

Alexander Davidson, MPH1; Sally Slavinski, DVM1; Kendra Komoto1; Jennifer Rakeman, PhD1; Don Weiss, MD1 1New York City Department of Health and Mental Hygiene, New York. Corresponding author: Sally Slavinski, [email protected], 347-396-2672.

Suspected Female-to-Male Sexual Transmission of Zika Virus — New York City, 2016Early Release / July 15, 2016 / 65 http://www.cdc.gov/mmwr/volumes/65/wr/mm6528e2.htm?s_cid=mm6528e2_w

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Laboratory-confirmed travel-related cases of Zika virus in Ontario^ as of July 12, 2016Number of laboratory-confirmed*casesCountries of Travel§86*Aruba, Barbados, Brazil, Columbia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Grenada, Guyana, Haiti, Honduras, Jamaica, Martinique, French West Indies, Mexico, Nicaragua, Panama, South Caribbean, Venezuela*Note: One of the 86 laboratory-confirmed cases of Zika virus in Ontario is non-travel related. http://health.gov.on.ca/en/public/publications/disease/zika.aspx

Laboratory-confirmed travel-related cases of Zika virus in Ontario^ as of July 12, 2016Number of laboratory-confirmed*casesCountries of Travel§86*Aruba, Barbados, Brazil, Columbia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Grenada, Guyana, Haiti, Honduras, Jamaica, Martinique, French West Indies, Mexico, Nicaragua, Panama, South Caribbean, Venezuela*Note: One of the 86 laboratory-confirmed cases of Zika virus in Ontario is non-travel related.

Zika virus cases in Canada, as of July 14, 2016 http://www.healthycanadians.gc.ca/diseases-conditions-maladies-affections/disease-maladie/zika-virus/surveillance-eng.php?id=zikacases#s1 CountryLocally acquired through sexual transmissionTravel-relatedCanada1149

Zika virus cases in Canada, as of July 14, 2016CountryLocally acquired through sexual transmissionTravel-relatedCanada1149

SummaryWHO and partners established a definition of what constitutes an outbreak, endemic transmission, and the interruption of mosquito-borne transmission in order to better characterize the level of transmission of Zika virus infection (Table 1, Fig. 2). This classification system was put into use as of the situation report of 7 July 2016.As of 13 July 2016, 65 countries and territories (Fig. 1, Table 1) have reported evidence of mosquito-borne Zika virus transmission since 2007 (62 of these countries and territories have reported evidence of mosquito-borne Zika virus transmission since 2015):48 countries and territories with a first reported outbreak from 2015 onwards (Table 1).Four countries are classified as having possible endemic transmission or have reported evidence of local vector-borne Zika infections in 2016.13 countries and territories have reported evidence of local vector-borne Zika infections in or before 2015, but without documentation of cases in 2016, or with outbreak terminated.No new country or territory has reported mosquito-borne Zika virus transmission in the week to 13 July 2016.Eleven countries have reported evidence of person-to-person transmission of Zika virus, probably via a sexual route (Table 2).As of 13 July 2016, microcephaly and other central nervous system (CNS) malformations potentially associated with Zika virus infection or suggestive of congenital infection have been reported by 13 countries or territories. Three of those countries reported microcephaly cases born from mothers with a recent travel history to Zika-affected countries in the WHO Region of the Americas (Table 3).As of 13 July 2016, the United States Centers for Disease Control and Prevention (US-CDC) reported seven live-born infants with birth defects and five pregnancy losses with birth defects with laboratory evidence of Zika virus infection.In the context of Zika virus circulation, 15 countries and territories worldwide have reported an increased incidence of Guillain-Barré syndrome (GBS) and/or laboratory confirmation of a Zika virus infection among GBS cases. French Guiana recently confirmed four cases of GBS and one severe neurologic condition, all of which were confirmed positive for Zika virus.Based on research to date, there is scientific consensus that Zika virus is a cause of microcephaly and GBS.In Guadeloupe, there are four GBS cases confirmed with Zika virus infection, and 12 additional GBS cases under investigation. Five cases of other severe neurological syndrome were confirmed with Zika virus infection. Zika virus was probable or confirmed for 11 cases of unidentified neurological syndrome.One neurologic condition laboratory confirmed for Zika virus infection was reported in Saint Martin.In Guinea-Bissau, on 29 June 2016, Institute Pasteur Dakar (IPD) confirmed that three of 12 samples tested positive for Zika by PC-R. All 12 samples tested negative against IgM Zika. Four additional samples were sent to IPD on 1 July for gene sequencing and the results are still pending.The government of Guinea-Bissau with support from the WHO Country Office (WCO) is demonstrating strong leadership in response to these findings. The WCO has availed funds to support the logistical needs of the response activities. The WHO assessment mission to Guinea-Bissau will be conducted to help identify the priority activities and to strengthen the national response capacity.On 13 July 2016, the U.S. CDC released a risk assessment for Zika virus spread related to travel to Olympics. The assessment concluded that international spread of Zika related to the Games would not significantly alter spread, but that four countries were at special risk, because residents of those countries did not have substantial travel to Zika affected countries, outside of potential exposure at the Olympics: Eritrea, Djibouti, Chad, and Yemen.The global Strategic Response Framework launched by WHO in February 2016 encompasses surveillance, response activities and research. An interim report describing some of the key activities being undertaken jointly by WHO and international, regional and national partners in response to this public health emergency was published on 27 May 2016. A revised strategy for the period of July 2016 to December 2017 was published on 17 June.WHO has developed advice and information on diverse topics in the context of Zika virus. WHO’s latest information materials, news and resources to support corporate and programmatic risk communication and community engagement are available online. Download the image jpg, 384kb

Zika situation report14 July 2016Zika virus, Microcephaly and Guillain-Barré syndromeRead the full situation reporthttp://who.int/emergencies/zika-virus/situation-report/14-july-2016/en/

July 14, 2016 DEPARTMENT OF HEALTH DAILY ZIKA UPDATE: NO NEW CASES TODAY http://www.floridahealth.gov/newsroom/2016/07/071416-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 no new cases today. According to CDC, symptoms associated with the Zika virus last between seven to 10 days. 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 43, with 12 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 43 Charlotte 1 Citrus 2 Clay 3 Collier 4 Duval 6 Escambia 1 Highlands 1 Hillsborough 6 Lake 1 Lee 6 Martin 1 Miami-Dade 78 Okaloosa 1 Orange 25 Osceola 12 Palm Beach 13 Pasco 5 Pinellas 7 Polk 8 Santa Rosa 1 Seminole 9 St. Johns 2 St. Lucie 1 Volusia 2 Total cases not involving pregnant women 250 Cases involving pregnant women regardless of symptoms* 43 *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 2,285 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 27 counties included in the declaration– Alachua, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Highlands, Hillsborough, Lake, Lee, Martin, Miami-Dade, Okaloosa, 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 5,136 people for active Zika virus and 1,621 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.

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--- PRESS RELEASE ---For Immediate Release DCHHS Reports 15th Zika Virus Case in Dallas County DALLAS (July 14, 2016) – Dallas County Health and Human Services (DCHHS) is reporting the 15th case of Zika virus in Dallas County in 2016. The case was confirmed through testing in a private lab. DCHHS has submitted the case for review to the Texas Department of State Health Services. The 40-year-old patient is a resident of Irving who was infected with the virus during recent travel to Puerto Rico. For medical confidentiality and personal privacy reasons, DCHHS does not provide additional identifying information. While sexual transmission of Zika virus is possible, it is primarily transmitted to people by Aedes species mosquitoes. The most common symptoms of Zika virus are fever, rash, joint pain, and conjunctivitis (red eyes). The illness is usually mild with symptoms lasting several days to a week. DCHHS advises individuals with symptoms to see a healthcare provider if they visited an area where Zika virus is present or had sexual contact with a person who traveled to an area where Zika virus is present. There is no specific medication available to treat Zika virus and there is not a vaccine. The best ways to avoid Zika virus are to avoid mosquito bites and sexual contact with a person who has Zika virus. There are currently no reports of Zika virus being locally-transmitted by mosquitoes in Dallas County. However, imported cases make local spread by mosquitoes possible because the mosquitoes that can transmit the virus are found locally. DCHHS advises recent travelers with Zika virus symptoms as well as individuals diagnosed with the virus to protect themselves from further mosquito bites. # For additional information, contact: YaMonica Sadberry, Administrative [email protected] 214.819.6070 (office) Zachary Thompson, Director 214.755.9299 (cell)

The 40-year-old patient is a resident of Irving who was infected with the virus during recent travel to Puerto Rico. For medical confidentiality and personal privacy reasons, DCHHS does not provide additional identifying information.

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Number of cases reportedCounty/Area TodayYear to Date (7/14/16) Albany03Broome01Clinton01Dutchess05Erie02Lewis01Monroe03Nassau020Niagara01Oneida02Onondaga04Ontario13Orange01Putnam01Rockland05St Lawrence01Schenectady01Suffolk027Tompkins01Westchester08NYS (ex NYC)191NYC8328NYS Total Confirmed9419NYS Pregnant Registry022NYS Total9441

A baby boy born with microcephaly in Harris County is the first known Zika-affected infant in the state, the Texas Department of State Health Services announced Wednesday. The baby’s mother contracted Zika in Colombia, and the baby was infected in the womb, according Umair Shah, executive director of Harris County Public Health. The baby was born a few weeks ago outside of Houston, and tests confirmed that he had Zika on Monday, Shah said. http://www.star-telegram.com/news/state/texas/article89464417.html