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First Travel-Related Case of Zika Confirmed in Stanislaus County STANISLAUS COUNTY -- Stanislaus County Health Services Agency has confirmed that a 19- year-old male county resident has tested positive for Zika virus. The affected individual contracted the virus during travel outside of the United States. http://www.stancounty.com/news-room/news-releases/news-2016/pdf/press-release-20160617-zika.pdf

June 20, 2016 DEPARTMENT OF HEALTH DAILY ZIKA UPDATE: FOUR NEW TRAVEL-RELATED CASES TODAY Contact: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 four new travel-related cases today with one in Broward, one in Highlands, one in Hillsborough and one in Palm Beach Counties. The Declaration of Public Health Emergency has been amended to include Highlands County. Of the cases confirmed in Florida, 16 are still exhibiting symptoms. 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 39, with 9 having met the previous CDC case definition. County Number of Cases (all travel related) Alachua 4 Brevard 4 Broward 26 Clay 2 Collier 2 Duval 1 Escambia 1 Hillsborough 5 Highlands 1 Lee 5 Martin 1 Miami-Dade 58 Orange 12 Osceola 6 Palm Beach 11 Pasco 2 Pinellas 5 Polk 3 Santa Rosa 1 Seminole 6 St. Johns 2 Volusia 2 Total cases not involving pregnant women 160 Cases involving pregnant women regardless of symptoms* 39 *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 2,091 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 21 counties included in the declaration– Alachua, Brevard, Broward, Clay, Collier, Duval, Escambia, Hillsborough, Highlands, Lee, Martin, Miami-Dade, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Santa Rosa, Seminole, St. Johns 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 Rick 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 Centers for Diseases Control (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.Florida currently has the capacity to test 5,790 people for active Zika virus and 1,613 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.Based on CDC guidance released, DOH will now report pregnant women with evidence of Zika virus regardless of symptoms. Prior to new guidance, CDC guidance was only to report cases of Zika if the pregnant women was symptomatic.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. http://www.floridahealth.gov/newsroom/2016/06/062016-zika-update.html

County Number of Cases (all travel related) Alachua 4 Brevard 4 Broward 26 Clay 2 Collier 2 Duval 1 Escambia 1 Hillsborough 5 Highlands 1 Lee 5 Martin 1 Miami-Dade 58 Orange 12 Osceola 6 Palm Beach 11 Pasco 2 Pinellas 5 Polk 3 Santa Rosa 1 Seminole 6 St. Johns 2 Volusia 2 Total cases not involving pregnant women 160 Cases involving pregnant women regardless of symptoms* 39 *Counties of pregnant women will not be shared.

Pennsylvania Blood Tests Submitted for Zika TestingInformation updated Mondays at 2 p.m. CDC Confirmed Cases: 24Pending Test Results: 238 Last update: 06/20/2016

baby was born with microcephaly in IbagueThis case could be associated with the Zika virus.Caracol Radio20/06/2016 - 14:11The Ministry of Health of Ibagué confirmed that in the city and was born the first baby with microcephaly severe that could be related to thevirus Zika. However, it is still waiting for the Ministry of Social Protection and the National Institute of health confirm whether the disease of the newborn is because the mother was infected with the virus during pregnancy. According to Health Secretary Salazar Valentina, the baby was born in Tolima Clinic and, today, still in hospital with his mother. While microcephaly is related to several factors, it is likely that in this case is related to the virus Zika . Today the Secretary will be making an official statement on the case. http://caracol.com.co/emisora/2016/06/20/ibague/1466424706_294294.html

Zika Virus – June 20, 2016. Texas has had 46 reported cases of Zika virus disease. Of those, 45 were in travelers who were infected abroad and diagnosed after they returned home; one of those travelers was a pregnant woman. One case involved a Dallas County resident who had sexual contact with someone who acquired the Zika infection while traveling abroad. Texas Zika Cases by County: CountyCasesBexar6Collin2Dallas9Denton2Ellis1Fort Bend2Grayson1Harris13Lubbock1Tarrant4Travis2Val Verde1Williamson1Wise1Total46

Allegheny County Residents Approved for Zika Testing: 111 CDC Confirmed Cases: 4(as of June 20)

Sunday June 19, 2016 5:21 pm The Ministry of Health of Tolima informs the public that last Thursday was born in Tolima Clinic a child with congenital malformation (microcephaly) but not confirmed as a case associated with the Zika virus. Therefore the Secretariat wishes to clarify the following: 1 . The Secretariat is not the entity to confirm positive cases of the Zika virus in pregnant women. This responsibility is the Ministry of Health and Social Protection and the National Institute of Health (NIH). 2. The child born with congenital malformation last week is one of the 4 cases of suspected pregnancies associated with the zika reported at the time that the virus Secretariat to INS. He was born with a gestational age of 37 weeks, the son of a mother of 22 years old and was incarcerated at UCI. It is stable awaiting test results to determine alterations. 3. After this birth INS practice 10 molecular tests to determine possible causes of the malformation that can be infectious, genetic, environmental or Zika virus. It is not known with certainty how long the results will be known. Positive or negative case, the INS will forward the respective tab congenital malformations to the Secretariat. 4. A Week 22 Tolima has reported 5,594 cases of which 687 are pregnant and which 4 cases are suspected to congenital malformation associated with Zika. 5. In Colombia born every year 140 cases for various reasons and in Tolima 3 to 5 year. To date the country has not confirmed any microfefalia birth associated with Zika. 6. The Ministry of Health Department will continue its monitoring work for the notification to the INS and enforce the relevant protocols. The Ministry of Health of Tolima continue to provide the support to institutions and the wider community through prevention campaign was Task looking and is the Zika. http://tolima.gov.co/publicaciones.php?id=13914

It investigates whether the case of microcephaly is related to zikaThe Ministry of Health Department reported that a few days ago a baby was born in Tolima Clinic with congenital malformation (microcephaly), although it has raised the possibility that the status of the newborn is related to the zika, the Secretariat said that this does not you can set yet.The baby was born with a gestational age of 37 weeks. (Photo: COLPRENSA - NEW DAY) 0 0Blogger0Google +0 New June 20, 2016 - 5:01Why he said that the only entities to determine the causes of the malformation, is the Ministry of Health and the National Institute of Health, NIH. "He boy born with congenital malformation last week is one of four suspected cases of Zika virus associated with pregnancies that the Secretariat reported to the INS, "said the Portfolio through a statement. Once known the case, the Institute shall proceed with 10 molecular tests to determine the cause of the baby's condition. At this point oriented infectious, genetic, environmental or zika origin hypothesis are handled. Similarly, a brain scan, ophthalmologic evaluation, hearing, consultation genetics and pediatric neurology is performed. official report Until April the national government had confirmed two cases of newborns affected by zika. Also, there is an official report that in Colombia, recorded 140 per year related to microcephaly, births of this figure in Tolima there are between three and five per year. In the epidemiological bulletin No 23 INS, 874 cases have been reported in pregnant women, this figure 403 are confirmed, 461 are suspects clinic and 10 are suspected in municipalities without diagnostic confirmation. The National Institute of Health, explains that "between epidemiological weeks 1 through 23 of 2016 have confirmed six cases of microcephaly associated with Zika virus, 50 cases were dismissed and 81 are under consideration." Also that of the "notified of neurological syndromes with a history of illness compatible with Zika virus infection, by territorial entity of residence during the special supervision, in Tolima 20 cases have been reported." Finally, the Ministry of Health of the Department, continue to carry out the work of monitoring and reporting to the INS. Similarly, the campaigns will be strengthened prevention in all municipalities in the region, he reported that dependency. - See more at: http://www.elnuevodia.com.co/nuevodia/tolima/regional/289336-se-investiga-si-caso-de-microcefalia-esta-relacionado-con-zika#sthash.IRl7IUs4.dpuf

Study first case of microcephaly in Ibague I might be related to the zikaLOCALTOLIMAJune 20, 2016 - 6:10 Am - If microcephaly in Ibagué be related to the zika Photo: RCN Radio National Institute of Health has not yet confirmed that the virus transmitted by aedes aegypti vector is the cause of the disease the child. Sandra Liliana Torres, secretary of health department revealed that the baby was born in Tolima clinic with microcephaly however, is not confirmed that the zika would have caused the condition. The minor is one of four suspected cases of pregnancies was associated with virus zika in the region. "He was born with a time of 37 weeks gestation, the son of a mother of 22 years old and was placed in intensive care clinic. The baby is stable awaiting test results to determine alterations " so she said. The National Institute of Health practice 10 molecular tests to determine the cause of the malformation that can be infectious, genetic, environmental or zika virus. In Tolima 5,594 cases have been reported of which 687 are pregnant and four would be related to the zika.

Sandra Liliana Torres, secretary of health department revealed that the baby was born in Tolima clinic with microcephaly however, is not confirmed that the zika would have caused the condition. The minor is one of four suspected cases of pregnancies was associated with virus zika in the region. "He was born with a time of 37 weeks gestation, the son of a mother of 22 years old and was placed in intensive care clinic. The baby is stable awaiting test results to determine alterations " so she said. http://www.rcnradio.com/locales/estudian-primer-caso-microcefalia-ibague-estaria-relacionado-zika/

Volume 22, Number 8—August 2016LetterFebrile or Exanthematous Illness Associated with Zika, Dengue, and Chikungunya Viruses, Panamahttp://wwwnc.cdc.gov/eid/article/22/8/16-0292_article

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FiguresFigure 1. Estimated percentage of blood donations positive for chikungunya virus (CHIKV) RNA during a chikungunya epidemic, Puerto Rico, USA, 2014. CHIKV RNA-positive minipools of 16 donors were used to estimate...Figure 2. Viral loads for chikungunya virus (CHIKV) in blood donations during a chikungunya epidemic, Puerto Rico, USA, 2014. A) Positive minipool (MP) viral loads. Estimated viral loads (RNA copies/mL) were...Figure 3. Serosurvey for chikungunya virus IgG in blood donations during a chikungunya epidemic, Puerto Rico, USA, 2014. Preepidemic samples collected in June and July 2014 were tested by using an...TablesTable 1. Nucleic acid amplification testing for chikungunya virus in minipools of blood donations during a chikungunya epidemic, Puerto Rico, USA, 2014Table 2. Individual blood donations tested for chikungunya virus by nucleic acid amplification testing and serologic analysis during a chikungunya epidemic, Puerto Rico, USA, 2014Table 3. Demographic characteristics of blood donors tested for chikungunya virus during a chikungunya epidemic, Puerto Rico, USA, 2014

DiscussionLarge epidemics of CHIKV infection occurred in the Caribbean Islands and in Central and South America over the past 2 years. Although >1.5 million confirmed and suspected cases have been reported (29), continued monitoring of CHIKV in these immunologically naive populations is needed for understanding population immunity and predicting dynamics of future epidemics. Using MP-NAAT, we estimated that 0.58% of individual blood donations were positive for CHIKV RNA during August 2014, a finding that is consistent with reported rates for Puerto Rico (12) and other Caribbean Islands (22). As the 2014 epidemic in Puerto Rico continued, proportions of CHIKV viremia peaked in blood donors during September and October; >2% of donors were viremic, as indicated by individual donor NAAT results. During September and October, 1,440 chikungunya cases confirmed by real-time reverse transcription PCR were reported to the Puerto Rico Department of Health, which indicated sustained levels of CHIKV in the general population. However, reports of suspected chikungunya cases by month of illness onset received by the Puerto Rico Department of Health through passive surveillance peaked in August 2014 (Figure 1), which resulted in ≈14,000 suspected chikungunya cases in August, including 741 chikungunya cases confirmed by real-time reverse transcription PCR (Puerto Rico Department of Health, 2015, unpub. data). Several factors probably affect the relative frequency of viremia and seroincidence of CHIKV in blood donors compared with clinical cases documented in the general population, including the focal nature of the epidemic in Puerto Rico during 2014 in relation to blood donor center locations. It is also likely that many cases went unreported and that as the epidemic progressed many infected persons might not have sought medical care (13). Our finding that ≈25% of blood donors had serologic evidence of CHIKV infection after the 2014 epidemic supports these suggestions. Given a population of >3.5 million, and assuming that blood donors are representative of the total population of Puerto Rico with respect to risk for arbovirus transmission, a seroincidence of 23.5% would suggest that >800,000 persons were infected in Puerto Rico during the 2014 epidemic. Blood safety protocols in place during the study included a Puerto Rico Department of Health requirement for questioning of donors concerning symptoms in the month preceding donation and passive reporting of postdonation febrile illness. Thus, in the absence of specific NAAT screening, asymptomatic donors are likely to result in most viremic donations (30). It is not clear whether asymptomatic infection is correlated with lower viremia levels, and thus would decrease the likelihood of transfusion transmission. However, similar to previous findings (12), many presumably asymptomatic donors in our study had viral loads comparable with those for symptomatic patients (11,19), including some viral loads >108copies/mL. Most donations with low viral loads were IgM positive, which indicates recent acute infections. The proportion of these viremic specimens increased as the epidemic waned, and the percentage of ID-NAAT–only samples increased from 56% in September to 77% in November. Lower average viral copy numbers were also observed in November and December by testing of minipools. Furthermore, all RNA-positive donors in November were seropositive compared with only 78% of NAAT-reactive donors in September. We estimate that the RNA-detectable window for MP-NAAT was 5.1 days. This value matches viremic periods observed for experimentally infected nonhuman primates (31) but is somewhat shorter than estimates for symptomatic patients of 1–2 days before disease onset and 8 days postonset (9,11,32,33). This finding is probably caused by a loss in the ability to detect viremia at the 1:16 dilution inherent in creating minipools, but might be a reflection that this study was limited to asymptomatic persons who donated blood. In addition, we calculated a relatively short ramp-up period before MP-NAAT–detectable viremia (0.5 days) and a longer low-level (MP-NAAT negative) viremia at the end of acute infection after seroconversion (8 days). Nevertheless, the 5-day MP-NAAT–detectable period for high-titer viremia is probably the most infectious period in terms of transfusion transmission and transmission to mosquitoes. The overall threat CHIKV poses to the blood supply remains an open question that requires urgent attention, including in the continental United States, given the risk for travel-acquired and autochthonous transmission. In the absence of routine NAAT for CHIKV, and in regions where pathogen-reduction technology is not implemented, the largest threat is probably from donors with high viral loads who have not fully seroconverted because it can be assumed that donors with neutralizing IgG responses have a lower probability of transmitting an infectious dose to a recipient. Although convalescent-phase serum is protective in animal studies (34), the ability of IgM and IgG in viremic donors to mitigate CHIKV transfusion transmission requires further study. Likewise, if viral RNA screening is introduced, studies will be needed to evaluate the relative usefulness of ID versus MP-NAAT. In screening of 3,007 individual donations, we identified 7 viremic donors with only IgM responses. However, only 1 of these donors had viremia detected only by ID-NAAT. We also identified 2 seronegative donors who showed reactivity by ID-NAAT, but not minipool testing. Whether blood components from these donations, together with specimens in the so-called eclipse phase between acquisition of infection and detectable ID-NAAT reactivity, are infectious remains unanswered. In summary, our results indicated a sizable proportion of blood donors had detectable CHIKV RNA during the chikungunya epidemic in Puerto Rico in 2014. Several donations with high viremias were negative for IgM and IgG, which suggested that donors were in the peak phase of acute infection and highlights the risk for transfusion transmission. However, most viremic donations had low levels of viral RNA and were seropositive, which suggests recent subclinical infection and low risk for infectivity. However, these donors were healthy enough to donate blood. Finally, serosurveys before and after peak epidemic months showed that ≈25% of blood donors in Puerto Rico acquired CHIKV during the 2014 epidemic. On the basis of findings of this study, we are now conducting further investigations to determine the risk for transfusion transmission of CHIKV by virus RNA–positive transfusions and outcomes of infection in recipients. Dr. Simmons is an associate investigator at Blood Systems Research Institute, San Francisco, California, and an associate professor in laboratory medicine at the University of California, San Francisco. His research interests are emerging infectious diseases and the threat they pose to the blood supply. AcknowledgmentsWe thank Maesa Hanhan and Lani Palmer for providing technical assistance. This study was supported in part by contracts 200-2014-M-59495 and 200-2015-M-81883 from the Centers for Disease Control and Prevention.

ResultsOf 1,668 minipools tested, 1 was positive for DENV RNA, and 161 (9.7%) were positive for CHIKV RNA (Table 1). This finding indicates a minimum MP-NAAT–detectable infection rate of 0.6% (161 positive donations of 26,688 total donations), assuming only 1 of the 16 donations in each positive minipool was viremic. However, because the reactive minipool proportion peaked at 19.5% in September 2014 (Table 1), some pools would probably contain >1 viremic donation. Figure 1. Estimated percentage of blood donations positive for chikungunya virus (CHIKV) RNA during a chikungunya epidemic, Puerto Rico, USA, 2014. CHIKV RNA-positive minipools of 16 donors were used to estimate the percentage... Individual donations comprising reactive minipools were not archived for further testing. Thus, we could not directly determine numbers of reactive IDS per reactive minipool. Therefore, we used a published algorithm (25) to estimate the proportion of donations that would contain CHIKV RNA at levels detectable by MP-NAAT (Table 1). This modification yielded an estimate for MP-NAAT detectable viremia of 0.65% for the overall season and an upper limit of 0.93%. The highest estimated proportion of MP-NAAT–detectable CHIKV RNA-positive donations was during September and October (1.34% and 1.31% of donations reactive for CHIKV RNA by MP-NAAT, respectively) (Table 1). This estimation represented a slightly delayed peak when compared with suspected and confirmed clinical cases reported in Puerto Rico (Figure 1). Figure 2. Viral loads for chikungunya virus (CHIKV) in blood donations during a chikungunya epidemic, Puerto Rico, USA, 2014. A) Positive minipool (MP) viral loads. Estimated viral loads (RNA copies/mL) were calculated for... Although not optimized to be quantitative, the TC-TMA assay provided approximate viral RNA copy numbers (Figure 2, panel A). Several minipools, particularly from early in the epidemic, had >107 copies/mL, although they were tested as a minipool, and thus effectively diluted 1:16. Of 161 reactive minipools, 125 had quantifiable viral loads. Remaining minipools had viral loads less than an estimated value of 0.5 log copies/mL (according to the calibration curve). The median viral load of 161 reactive minipools was 550 copies/mL (range <3.16 copies/mL–2.3 × 107 copies/mL). Donations from November and December had lower viral loads than donations from preceding months. We also performed testing of archived IDS for CHIKV RNA for 3,007 donations collected in Puerto Rico during September–November 2014. We identified 56 confirmed positive donations, and ID-NAAT yields were 1.7%–2.1% for the 3 months tested (Table 2). When samples were diluted 1:16 to mimic minipools, proportions of RNA-positive samples detectable by MP-NAAT for September–November decreased to 0.4%–0.9%. Only 21 (37.5%) of 56 ID-NAAT–reactive specimens were reactive when tested for CHIKV RNA at a dilution of 1:16. Thus, 35 (62.5%) of 56 specimens would probably have been missed by routine MP-NAAT (Table 2). As expected, viral loads were low in donations reactive only by ID-NAAT. Only 8 of the ID-NAAT only–reactive samples had quantifiable viral loads (range 5.2–760 copies/mL) (Figure 2, panel B). We performed assays to detect IgM and IgG in the 56 ID-NAAT–reactive specimens to characterize the relationship between development of IgG and IgM, viral load, and the ability of minipool testing to detect viremic donations (Table 2). Thirteen (23.2%) of 56 samples were seronegative; 2 were detectable only by ID-NAAT. These 2 samples are presumed to represent donors detected in the earliest stages of acute infection. The remaining 11 seronegative viremic donations had detectable viral loads (range 5 ×102–1.3 × 108 copies/mL) (Figure 2, panel B), including 8 (14.3%) of 56 with viral loads >104copies/mL. These samples were probably from donors who were near the peak of viremia, but still collected before seroconversion occurred. Most CHIKV RNA-reactive samples were IgM positive (75%) and IgG positive (64%); 1 sample was IgM negative and IgG positive. Development of IgG titers is an inverse correlate of CHIKV RNA detection (28); of the IgG-reactive samples, only 4 (11.1%) of 36 were detectable by the less sensitive MP-NAAT. Viral loads of samples sorted on the basis of NAAT results (ID only vs MP-NAAT detectable) and serologic data demonstrate a typical profile of acute viral infection (Figure 2, panel B). The 43 viremic IgM-positive or IgG-positive donations had significantly lower viral loads (median <3.16 copies/mL) than 13 viremic seronegative donations (60,000 copies/mL; p<0.0001 by 2-tailed Mann-Whitney test). Although similar proportions of ID-NAAT–positive samples were detected in November (1.7%) and September (1.8%), only 2 (11.8%) of 17 were seronegative in November compared with 6 (33.3%) of 18 in September, which suggested waning of the epidemic and a higher proportion of donations at the end of acute infection. To estimate the incidence of CHIKV infection during the 2014 epidemic, we performed IgG serologic studies on blood donor specimens collected at the beginning of the epidemic (June 2014; preepidemic) and after the epidemic had subsided (March 2015; postepidemic). Collection was delayed until March to maximize detection of IgG seroconversion and to enable the maximum period for potential donors to recover from symptomatic infection, which would result in self-deferral, or deferral by the blood collection organization. Figure 3. Serosurvey for chikungunya virus IgG in blood donations during a chikungunya epidemic, Puerto Rico, USA, 2014. Preepidemic samples collected in June and July 2014 were tested by using an IgG ELISA.... On the basis of IgG testing, we found that there were no unequivocally seroreactive samples in preepidemic samples (n = 201). In contrast, 241 (n = 1,031) postepidemic samples were strongly reactive (sample-to-calibrator ratio >2.5) (Figure 3). An additional indeterminate sample was positive by confirmatory testing with IgM ELISA, PRNT, and Western blot analysis. Thus, 242 (23.5%) of 1,031 samples were conservatively characterized as reactive (Figure 3). Before we relabeled samples so that CHIKV testing was anonymous, basic demographic data were extracted for many of the specimens from March 2015 tested for seroreactivity (Table 3). No differences were observed in seropositivity rates between men and women. Persons 16–19 years of age had the highest rate of CHIKV recent infection; 40 (43.0%) of 93 of these persons were seropositive. In contrast, only 30 (18.3%) of 164 persons 40–49 years of age were seropositive. We combined results from MP-NAAT and ID-NAAT screening and the serosurvey to estimate lengths of time that CHIKV RNA is detectable in serial stages of viremia in asymptomatic donors by MP-NAAT and ID-NAAT used in this study (Figure 2, panel B). We estimated that the length of the MP-NAAT–detectable phase for acute CHIKV infection in asymptomatic persons who donated blood was 5.1 days (confidence limit 4.1–6.0 days). By applying the ratios of seronegative ID-NAAT–only donations (2/56), MP-NAAT–detectable donations (21/56), and ID-NAAT–only seropositive donations (33/56), we estimated that there is a transient stage of low viral load infection preceding viremia detectable by MP-NAAT (0.5 days; confidence limit 0–1.3 days), whereas there is a relatively long stage of persistent viremia after seroconversion (8 days; confidence limit 2.7–13.3 days).

Materials and MethodsHuman Subjects Research ApprovalWe performed retrospective testing of anonymous blood donor samples and minipools. The study was approved by the University of California, San Francisco Committee for Human Research. SpecimensCreative Testing Solutions (Tempe, AZ, USA) retained, aliquoted, and archived at −70°C residual plasma from EDTA-anticoagulated blood collected in Puerto Rico and supplied for routine blood donor screening during the second half of 2014 and for a brief period during March 2015. Current molecular testing procedures at Creative Testing Solutions require that plasma samples be pooled into a minipool of 16 donor samples. Minipools prepared from blood donations in Puerto Rico were frozen during June 20–December 31, 2014. The sample set consisted of 1,667 minipools representing 26,672 individual donation samples from donors in Puerto Rico. Minipools were irreversibly stripped of their original labels and given a unique bar code that was linked only to month of collection. In addition, 3,007 individual donor samples (IDS) were collected during the epidemic (September–November 2014), and ≈1,000 samples were saved per month. IDS were irreversibly stripped of all identifying information and given a unique bar code. Only basic demographic data (donor’s age, race, sex, county of residence, and week of collection) were retained in a secure database. Anonymous minipools and individual donor samples were retained, aliquoted, frozen, and stored at −70°C. Finally, we retained 1,031 individual donation samples obtained during March 1–9, 2015, for a postepidemic serosurvey. Demographic data, including the donor’s age, sex, and zip code of residence, but not individual donor identifiers, were retained for these samples to enable analysis of serologic test results by using demographic strata. Viral RNA TestingWe performed viral RNA testing by using a prototype real-time CHIKV/dengue virus (DENV) target-capture, transcription-mediated amplification (TC-TMA) assay (12) (Hologic, Inc., San Diego, CA, USA). Plasma samples (0.5 mL) were tested by using the fully automated Panther System (Hologic, Inc.), which performs target capture, amplification, and real-time detection in the presence of an internal control. We achieved detection by using single-stranded, fluorescent-labeled nucleic acid probes that were present during amplification of the target. The time for the fluorescent signal to reach a specified threshold was proportional to the starting CHIKV and DENV RNA concentrations. Target capture oligonucleotides, TMA primers, and detection probes hybridize with highly conserved regions of CHIKV or DENV RNA genomes and were designed to detect all 3 major CHIKV lineages and all 4 DENV types. We set the cutoff value for reactive specimens at 1,000 relative fluorescent units. Estimated viral loads for CHIKV were calculated relative to the emergence time of the emitted fluorescence of a calibration curve generated by testing logarithmic dilutions of a CHIKV in vitro–synthesized transcript. ID-NAAT–reactive specimens were diluted 1:16 in defribrinated, delipidated, pooled plasma (SeraCare, Gaithersburg, MD, USA) to mimic minipool testing and tested by TC-TMA assay to assess whether donation samples detected by ID-NAAT would have been detectable by minipool NAAT (MP-NAAT). We determined limits of detection (LODs) by using an in vitro transcript corresponding to each analyte and calculation by using Enterprise Guide 5.1 Probit analysis and the Normal model (SAS Institute, Cary, NC, USA). For DENV-1–4, the 50% LOD was 1.7–2.1 copies/mL, and the 95% LOD was 7.1–13.0 copies/mL in the IDS format. For CHIKV, the 50% LOD was 4.6 copies/mL, and the 95% LOD was 19.7 copies/mL in the IDS format. In 16-member minipools for DENV-1–4, the 50% LOD was from 27.2–33.6 copies/mL, and the 95% LOD was 116.8–208.0 copies/mL. For CHIKV, the 50% LOD was 73.6 copies/mL, and the 95% LOD was 315.2 copies/mL in the MP format. Serologic AnalysisPlasma samples were tested for CHIKV IgM or IgG by using 2 ELISAs (Euroimmun US, LLC, Morris Plains, NJ, USA). These CHIKV ELISAs had specificities of 82% and 95% and sensitivities of 85% and 88% for IgM and IgG, respectively, when compared with those for 2 established in-house assays (23). Samples were diluted 1:100 and tested in duplicate according to the manufacturer’s instructions. Sample-to-calibrator ratios were calculated. In validating the assay, we found that preepidemic samples (n = 201) yielded no strongly positive samples when the manufacturer’s cutoff value >1.1 sample-to-calibrator ratio was used. However, 5 samples showed borderline reactivity (sample-to-calibrator ratios 1.13–1.37). These 5 samples did not show positive results by reflex IgM testing, plaque-reduction neutralization testing (PRNT), or Western blot analysis when cell culture–propagated virus (strain 99659) was used as antigen. Testing of randomly chosen highly and moderately IgG-reactive samples from March 2015 by PRNT showed strong neutralization in all instances. Thus, the assay does not appear to yield strongly reactive false-positive results, but might yield a small frequency (5/201, 2.5%) of low-level reactive false-positive results. Therefore, a new cutoff value was established by using mean sample-to-calibrator ratios of preepidemic samples plus 5 SDs (1.42). Testing of multiple IgG-negative samples from both sample sets by IgM ELISA (20 samples), PRNT (20 samples), and Western blot analysis (10 samples) did not yield any suspected false-negative results, which suggested that false-negative results were also not common. Estimation of Detection Periods for MP-NAAT and IDS-NAATOn the basis of the estimate for incidence of infection during the 2014 epidemic derived from serosurveys and MP-NAAT–positive results for the study period, we derived an estimate for duration of viremia detectable by the CHIKV TMA NAAT applied to minipools by using the approach of Busch et al. (24). We estimated the number of NAAT-positive donations in each minipool from minipool-testing results by using a program developed at the Centers for Disease Control and Prevention (Atlanta, GA, USA) (25). If Ti is the proportion of NAAT-positive donations in month i and P is seroprevalence of CHIKV at the end of the epidemic, then the TMA detection interval of CHIKV virus RNA (W) is estimated as Confidence limits for W were estimated by using a delta method estimate of the variance of W. Estimates for length of the individual donor sample-positive detection periods preceding and following the MP-NAAT–detectable period were derived from results of screening 3,007 individual donor samples by using ratios of samples detectable only by ID-NAAT that lacked IgG or contained IgG relative to the number of samples detectable at a dilution of 1:16. Confidence limits for these detection periods were derived by bootstrapping the assay results ratios (2/21) and (33/21) to obtain their variances, and then combining those with the variance associated with the estimate for the minipool detection period to obtain the variance of each of the 2 window estimates.

Chikungunya virus (CHIKV), a mosquitoborne, positive-sense RNA virus of the familyTogaviridae, causes an acute febrile illness and severe polyarthralgia that can persist for months or years in some patients (1–3). Serious outcomes and deaths are rarely observed. However, newborns and other vulnerable populations are at risk for severe complications (4). In late 2013, cases of CHIKV infection were reported in the French Collectivity of Saint Martin, which is part of the French Antilles (5), constituting the first instance of autochthonous transmissions of CHIKV in the Americas in the past century (6). In an immunologically naive population, CHIKV spread rapidly throughout the Caribbean region and beyond to most countries in the Western Hemisphere (7), including 11 autochthonous cases reported in Florida, USA, in September 2014 (8). CHIKV has yet to be demonstrated to be transmissible by blood transfusion (9). However, this finding might result from difficulties in discriminating transfusion transmission from locally acquired mosquitoborne infection. Transfusion transmission is probable, given previous instances of laboratory-acquired infections and infection of healthcare workers by blood exposures (10). Asymptomatically infected persons can have viral loads >105 PFU/mL (11,12) and are a substantial risk for transfusion transmission. Estimates of asymptomatic CHIKV infection vary widely. A recent study in Puerto Rico (13) confirmed previous estimates that 10%–25% of total infections are subclinical (14–16). However, other studies with the Asian genotype suggest that a greater proportion of cases might be asymptomatic or have only mild and transient symptoms (17,18). CHIKV infection can result in viral loads >108 PFU/mL (19). Thus, relatively high viral loads likely present in some presymptomatic donors might be a threat for transfusion transmission. Recently, a case of transfusion transmission of the related alphavirus Ross River virus, has been reported (20), stemming from transfusion of the erythrocyte component from a blood donor who reported symptoms of Ross River virus infection 2 days after donating blood. To mitigate the theoretical risk for transmission, some blood collection organizations in regions with large CHIKV epidemics have suspended local blood collection, implemented nucleic acid amplification testing (NAAT) of erythrocyte and plasma donations for CHIKV RNA, and introduced pathogen-reduction technology for platelet components (21,22). To directly assess the threat that CHIKV poses to the blood supply, and given the absence of licensed NAAT for donor screening, we conducted NAAT surveys of blood donors in Puerto Rico during the 2014 epidemic and complementary serosurveys before and after the epidemic.

AbstractChikungunya virus (CHIKV) caused large epidemics throughout the Caribbean in 2014. We conducted nucleic acid amplification testing (NAAT) for CHIKV RNA (n = 29,695) and serologic testing for IgG against CHIKV (n = 1,232) in archived blood donor samples collected during and after an epidemic in Puerto Rico in 2014. NAAT yields peaked in October with 2.1% of donations positive for CHIKV RNA. A total of 14% of NAAT-reactive donations posed a high risk for virus transmission by transfusion because of high virus RNA copy numbers (104–109 RNA copies/mL) and a lack of specific IgM and IgG responses. Testing of minipools of 16 donations would not have detected 62.5% of RNA-positive donations detectable by individual donor testing, including individual donations without IgM and IgG. Serosurveys before and after the epidemic demonstrated that nearly 25% of blood donors in Puerto Rico acquired CHIKV infections and seroconverted during the epidemic.

Graham Simmons , Vanessa Brès, Kai Lu, Nathan M. Liss, Donald J. Brambilla, Kyle R. Ryff, Roberta Bruhn, Edwin Velez, Derrek Ocampo, Jeffrey M. Linnen, Gerardo Latoni, Lyle R. Petersen, Phillip C. Williamson, and Michael P. BuschAuthor affiliations: Blood Systems Research Institute, San Francisco, California, USA (G. Simmons, K. Lu, N.M. Liss, R. Bruhn, M.P. Busch); University of California, San Francisco (G. Simmons, M.P. Busch); Hologic, Inc., San Diego, California, USA (V. Brès, D. Ocampo, J.M. Linnen); RTI International, Rockville, Maryland, USA (D.J. Brambilla); Puerto Rico Department of Health, San Juan, Puerto Rico, USA (K.R. Ryff); Banco de Sangre de Servicios Mutuos, San Juan, Puerto Rico, USA (E. Velez, G. Latoni); Centers for Disease Control and Prevention, Fort Collins, Colorado, USA (L.R. Petersen); Creative Testing Solutions, Tempe, Arizona, USA (P.C. Williamson) Suggested citation for this article: Simmons G, Brès V, Lu K, Liss NM, Brambilla DJ, Ryff KR, et al. High incidence of chikungunya virus and frequency of viremic blood donations during epidemic, Puerto Rico, USA, 2014. Emerg Infect Dis. 2016 Jul [date cited]. http://dx.doi.org/10.3201/eid2207.160116 DOI: 10.3201/eid2207.160116

Volume 22, Number 7—July 2016ResearchHigh Incidence of Chikungunya Virus and Frequency of Viremic Blood Donations during Epidemic, Puerto Rico, USA, 2014http://wwwnc.cdc.gov/eid/article/22/7/16-0116_article

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Johnson County, Kan. (June 18, 2016) – The Johnson County Department of Health and Environment (JCDHE) received test results that confirm the first travel-associated case of Zika virus in Johnson County. The person tested has a history of travel to an area where mosquitoes are spreading Zika virus http://www.jocogov.org/sites/default/files/documents/DHE/PBH/Zika Travel News Release.pdf