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Emilio Dirlikov, PhD1,2; Kyle R. Ryff, MPH1; Jomil Torres-Aponte, MS1; Dana L. Thomas, MD1,3; Janice Perez-Padilla, MPH4; Jorge Munoz-Jordan, PhD4; Elba V. Caraballo, PhD4; Myriam Garcia5,6; Marangely Olivero Segarra, MS5,6; Graciela Malave5,6; Regina M. Simeone, MPH7; Carrie K. Shapiro-Mendoza, PhD8; Lourdes Romero Reyes9; Francisco Alvarado-Ramy, MD10; Angela F. Harris, PhD11; Aidsa Rivera, MSN4; Chelsea G. Major, MPH4,12; Marrielle Mayshack1,12; Luisa I. Alvarado, MD13; Audrey Lenhart, PhD14; Miguel Valencia-Prado, MD15; Steve Waterman, MD4; Tyler M. Sharp, PhD4; Brenda Rivera-Garcia, DVM1 1Office of Epidemiology and Research, Puerto Rico Department of Health; 2Epidemic Intelligence Service, Division of Scientific Education and Professional Development, CDC; 3Division of State and Local Readiness, Office of Public Health Preparedness and Response, CDC; 4Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 5Biological and Chemical Emergencies Laboratory, Office of Public Health Preparedness and Response, Puerto Rico Department of Health; 6Public Health Laboratory, Puerto Rico Department of Health; 7Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, CDC; 8Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC ; 9Puerto Rico Women, Infants, and Children Program; 10Division of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 11Bill & Melinda Gates Foundation, Seattle, WA; 12Office for State, Tribal, Local, and Territorial Support, CDC; 13Ponce Health Sciences University-Saint Luke’s Episcopal Hospital Consortium, Puerto Rico; 14Division of Parasitic Diseases and Malaria, Center for Global Health, CDC; 15Puerto Rico Birth Defects Surveillance and Prevention System, Puerto Rico Department of Health.

Update: Ongoing Zika Virus Transmission — Puerto Rico, November 1, 2015–April 14, 2016Early Release / April 29, 2016 / 65 http://www.cdc.gov/mmwr/volumes/65/wr/mm6517e2.htm?s_cid=mm6517e2_w

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First case of Zika virus infection confirmed in New Brunswick29 April 2016 FREDERICTON (GNB) – The Department of Health has confirmed the first case of Zika virus infection in New Brunswick. An individual recently travelled to an area affected by the outbreak. The person did not require hospitalization after contracting the virus and has recovered from the illness. “The overall risk to New Brunswickers is very low as the species of mosquitoes that can carry the virus are unable to survive the cool weather in New Brunswick or Canada,” said Dr. Jennifer Russell, acting chief medical officer of health. The Zika virus is transmitted to people primarily through the bites of infected mosquitoes. Affected areas include the Americas, the southern and western Pacific, and some African and Asian countries. The mosquito species are not found in Canada due to the climate. Travellers to areas affected by the outbreak and to areas at risk of an outbreak can protect themselves against the virus by taking individual protective measures to prevent mosquito bites including using insect repellent, wearing protective clothing, using mosquito nets, and ensuring that doors and windows are screened. It is recommended that pregnant women avoid travel to areas with a Zika virus outbreak or to areas at risk of an outbreak. If travel cannot be postponed, then strict mosquito bite prevention measures should be followed. Women wishing to get pregnant should wait at least two months after they return from countries where the virus is circulating before trying to conceive. Transmission of the Zika virus through semen has been reported but is very rare. Men who have travelled to a country with an ongoing outbreak should use condoms with any partner who could become pregnant for six months after their return. It is recommended that men who have a pregnant partner should use condoms for the duration of the pregnancy. To prevent spreading the virus through sex, couples should use condoms consistently and correctly every time they have sex. Those traveling to affected areas should take the following measures: Protect yourself from mosquito bites at all times, as the virus is transmitted by a mosquito that can bite in daylight and evening hours.Cover up: light-coloured, long-sleeved, loose fitting, tucked-in shirts, long pants, shoes or boots (not sandals), and a hat.Use insect repellent on exposed skin: insect repellents that contain DEET or Icaridin are the most effective, and use as directed by the manufacturer.Consider your accommodations: stay in a well-screened or completely enclosed air-conditioned room.Sleep under a bed net, preferably one treated with insecticide.Apply a permethrin insecticide to clothing and other travel gear for greater protection.More information on the virus is available online. http://www2.gnb.ca/content/gnb/en/departments/health/news/news_release.2016.04.0340.html

Zika virus case confirmed in New BrunswickPerson infected had travelled to a region affected by the outbreak and has recoveredCBC News Posted: Apr 29, 2016 12:21 PM AT Last Updated: Apr 29, 2016 12:21 PM AT Acting Chief Medical Officer of Health Jennifer Russell advises anyone who is pregnant or who has hopes to become pregnant in the near future to see advice from a health professional about travel to countries where the Zika virus is present. (CBC) 5 shares Facebook Twitter Reddit Google Share Email Related StoriesZika virus outbreak an emergency, World Health Organization saysA case of Zika virus has been confirmed in New Brunswick, according to the province's acting chief medical officer of health, Dr. Jennifer Russell. The person who was infected with the virus had recently travelled to a region affected by the outbreak, said Russell in a news release. In February, the World Health Organization declared the mosquito-borne Zika virus outbreak in the Americas to be a public health emergency. The virus is mainly spread by bites from infected mosquitoes in the Caribbean, South and Central America. Aedes aegypti, the species of mosquito that carries Zika virus. (US Centers for Disease Control) "The overall risk to New Brunswickers is very low as the species of mosquitoes that can carry the virus are unable to survive the cool weather in New Brunswick or Canada," said Russell, acting chief medical officer of health. The virus can also be sexually transmitted. "Transmission of the Zika virus through semen has been reported but is very rare. Men who have travelled to a country with an ongoing outbreak should use condoms with any partner who could become pregnant for six months after their return," said the province's release. The person affected in New Brunswick did not require hospitalization and has recovered. http://www.cbc.ca/news/canada/new-brunswick/zika-new-brunswick-1.3558948

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Zika virus cases in Canada, as of April 28, 2016 Country Locally acquired through sexual transmission Travel-related Canada 1 59 http://www.healthycanadians.gc.ca/diseases-conditions-maladies-affections/disease-maladie/zika-virus/surveillance-eng.php?id=zikacases#s1

Zika virus cases in Canada, as of April 28, 2016 CountryLocally acquired through sexual transmissionTravel-related Canada 1 59

Zika Virus – April 29, 2016. Texas has had 31 confirmed cases of Zika virus disease. Of those, 30 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. Case counts by county: Bexar – 3Dallas – 6Denton – 1Fort Bend – 2Grayson – 1Harris – 12Tarrant – 3Travis – 2Wise – 1

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Table 3. Countries, territories and areas reporting microcephaly and /or CNS malformation cases potentially associated with Zika virus infection. Reporting country or territory Number of microcephaly and /or CNS malformation cases suggestive of congenital infections or potentially associated with a Zika virus infection Probable location of infection Brazil 11984 Brazil Cabo Verde 3 Cabo Verde Colombia 7 Colombia French Polynesia 8 French Polynesia Martinique 3 Martinique Panama 4 Panama Slovenia 1 Brazil United States of America 2 Brazil; Mexico, Belize or Guatemala (undetermined) http://apps.who.int/iris/bitstream/10665/205686/1/WHOsitrep_28Apr2016_eng.pdf?ua=1

Zika situation report28 April 2016Zika virus, Microcephaly and Guillain-Barré syndromeRead the full situation report Summary:As of 27 April, 55 countries and territories report continuing mosquito-borne transmission; for 42 countries this is their first documented Zika virus outbreak (Fig. 1). Mosquito-borne transmission (Table 1): 42 countries are experiencing a first outbreak of Zika virus since 2015, with no previous evidence of circulation, and with ongoing transmission by mosquitos.13 countries reported evidence of Zika virus transmission between 2007 and 2014, with ongoing transmission.Four countries or territories have reported an outbreak since 2015 that is now over: Cook Islands, French Polynesia, ISLA DE PASCUA – Chile and YAP (Federated States of Micronesia.Person-to-person transmission: Nine countries have reported evidence of person-to-person transmission of Zika virus, probably via a sexual route. In the week to 27 April, no additional countries reported mosquito-borne Zika virus transmission. Canada is the latest country to report person-to-person transmission.Microcephaly and other fetal malformations potentially associated with Zika virus infection or suggestive of congenital infection have been reported in six countries or territories (Table 3). Two cases, each linked to a stay in Brazil, were detected in Slovenia and the United States of America. One additional case, linked to a brief stay in Mexico, Guatemala and Belize, was detected in a pregnant woman in the United States of America.In the context of Zika virus circulation, 13 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.Based on research to date, there is scientific consensus that Zika virus is a cause of microcephaly and GBS.The global prevention and control strategy launched by the World Health Organization as a Strategic Response Framework encompasses surveillance, response activities and research. Key interventions are being undertaken jointly by WHO and international, regional and national partners in response to this public health emergency.WHO has developed new advice and information on diverse topics in the context of Zika virus. WHO’s latest information materials, news and resources to support risk communication, and community engagement are available online.http://who.int/emergencies/zika-virus/situation-report/28-april-2016/en/

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FOR IMMEDIATE RELEASEFirst Positive Case of Zika Confirmed in Sonoma CountySanta Rosa, CA – April 28, 2016 – Today, the Sonoma County Department of Health Services (DHS) confirmed an individual tested positive for the Zika virus in Sonoma County. This individual is the first case of Zika in our county. While traveling in Central America the Sonoma County resident was bit by mosquitoes. Spread of the Zika virus occurs primarily through infected Aedes mosquitoes which are present throughout the Caribbean, South and Central America. The mosquitoes that transmit the Zika virus have not been detected in Sonoma County. Currently, there is no risk for Zika to spread by mosquitoes here. However, the Zika virus can also be spread through sexual contact and from a mother to her unborn baby. “We anticipate more cases. Even though there is currently no risk for local transmission, our residents could be exposed to Zika virus through travel, sexual contact with travelers and from mothers to their unborn babies” stated Sonoma County Deputy Health Officer Dr. Karen Holbrook. “We want our residents to understand the risks and to take steps to protect themselves, their sexual partners and their babies.” In most people the illness is mild. The most common signs and symptoms of Zika virus infection are fever, rash, joint pain and conjunctivitis. However, rare neurological syndromes have been associated with Zika virus infection and during pregnancy, infection can lead to early pregnancy loss, microcephaly, absent or poorly developed brain structures, defects of the eye and impaired growth in fetuses and infants. Being careful about travel is the most effective way to protect oneself from Zika. Everyone should follow travel guidance from the Centers for Disease Control and Prevention (CDC). In particular, women who are pregnant or who may become pregnant should consider postponing travel to areas where the Zika virus is active. If travel is necessary, steps should be taken to avoid mosquitoes. If a pregnant woman’s male sexual partner has traveled to an area with active Zika spread, they should work together to abstain or use condoms correctly at all times throughout the pregnancy. “Everybody should follow these recommendations: if you must travel, do it safely; if you have sex, do it safely too,” said Dr. Holbrook. DHS is working with local healthcare providers to test for the Zika virus. The Department previously issued Health Advisoriesnotifying local providers about Zika and testing protocols. In addition, the Department is coordinating with the Marin Sonoma Mosquito & Vector Control District on education and response plans. The Vector Control District has a mosquito surveillance program underway for the detection of invasive Aedes mosquitoes. The peak time of year for mosquitoes is here in our community, and individuals should take precautions to help control mosquitoes - such as removing standing water from around their home. Also, daytime biting mosquitoes should be reported to the Vector Control District (1-800-231-3236 or online). Due to privacy concerns, DHS will not release the individual’s name, place of residence, age or any other identifying information. DHS will continue to provide updates on Zika as we learn more information. The list of countries with active Zika spread is changing each week so please visit the CDC’s website for the most updated information. http://wwwnc.cdc.gov/travel/page/zika-information. ### Contact InformationScott AlonsoCommunications CoordinatorHealth ServicesCounty of SonomaEmail: [email protected] HoursMonday – Friday8:00 AM – 5:00 PMContact us by PhoneWorkPhone: (707) 565-6625AddressOffice LocationHealth Services Administration3313 Chanate RoadSanta Rosa, CA 95404

Santa Rosa, CA – April 28, 2016 – Today, the Sonoma County Department of Health Services (DHS) confirmed an individual tested positive for the Zika virus in Sonoma County. This individual is the first case of Zika in our county. While traveling in Central America the Sonoma County resident was bit by mosquitoes. http://sonomacounty.ca.gov/Health/Press-Releases/2016/First-Positive-Case-of-Zika-Confirmed-in-Sonoma-County/

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The North Dakota Department of Health recently received confirmation from the Centers for Disease Control and Prevention that a woman who traveled to Puerto Rico while pregnant has tested positive for Zika virus. While Zika is associated with microcephaly and other birth defects, none have been identified in the infant. As a precaution, the NDDoH plans to monitor the infant for a year. The woman is the first North Dakota resident to test positive for Zika. https://health.nd.gov/media/1266/2016-04-28-zika-nr-final.pdf

Brain Damage in Zika Babies Is Far Worse Than Doctors ExpectedResearchers say the Zika virus attacks lobes of the fetal brain that control thought, vision, movement Janeusa Primo Chagas, head of neuropediatrics at a hospital in Salvador, Brazil, examines brain images. Hundreds of mothers in Brazil have given birth to babies with microcephaly that have disabilities more severe than in textbook cases. PHOTO:LUCIANA MAGALHAESBy LUCIANA MAGALHAES and BETSY MCKAYUpdated April 28, 2016 1:00 p.m. ET106 COMMENTSSALVADOR, Brazil—Ana Gabriela do Prado Paschoal sat at a desk in a small medical exam room and began a familiar, heartbreaking ritual. Your baby’s head is smaller than normal, Dr. Paschoal told the anxious mother, who had contracted the Zika virus while pregnant. The 3-month-old girl, Maria Luiza, also had lesions on her brain. Her muscles were stiffer than normal, a sign of brain damage. Maria Luiza would take longer to walk and talk, Dr. Paschoal told the mother, a 24-year-old farmworker. More serious complications were likely, but the doctor decided that was enough news for one day. The scale and severity of prenatal damage by the Zika virus are far worse than past birth defects associated with microcephaly, a condition characterized by a small head and brain abnormalities. Scans, imaging and autopsies show that Zika eats away at the fetal brain. It shrinks or destroys lobes that control thought, vision and other basic functions. It prevents parts of the brain not yet formed from developing. Related Video As many as 1.5 million Brazilians may be infected by the mosquito-borne Zika virus. With Brazil at the forefront of the latest global health scare, and as the host of this year’s Olympic Games, Dipti Kapadia explains three things Brazil is doing to combat the Zika virus. Photo: Getty Images Drugmakers are fast-tracking efforts to develop a vaccine to treat the Zika virus, which has been linked to serious birth defects. WSJ’s Peter Loftus reports. Photo: Scripps Research Institute“These aren’t just microcephaly, like a slightly small head. The brain structure is very abnormal,” said Jeanne Sheffield, director of maternal-fetal medicine at the Johns Hopkins School of Medicine, who has been counseling pregnant women about microcephaly for two decades. Microcephaly, a rare birth defect that affects about 6 out of 10,000 babies in the U.S., is often associated with developmental delays and intellectual disabilities. But some children are only mildly affected. The Zika-related cases in Brazil nearly all involve significant brain damage. The sickest Zika babies in Brazil have died before delivery or within hours of birth. No one knows yet how long the survivors will live or how much they can be helped in the years ahead. Brazil is now bracing for a second stage of the 6-month-old crisis: Caring for infants with a wide range of disabilities. Experts have begun calling the constellation of maladies linked to the virus Congenital Zika Syndrome—to describe the babies born with disabilities more severe than in textbook microcephaly cases. Often, liquid fills the spaces where there is no brain tissue. Brazilian Silvia Leandra de Jesus Pinheiro says her life has been turned upside down since her daughter Geovanna was born in October with microcephaly. The baby’s physicians have told her that Geovanna could have trouble with speech and movement. ‘My hope is that she gets there, even if it’s after other kids her age,’ she said. PHOTO: LUCIANA MAGALHAES“There are areas of the brain that aren’t even formed,” said Janeusa Primo Chagas, head of neuropediatrics at the hospital operated by Sister Dulce, a philanthropic organization, where Dr. Paschoal also works. Baby Maria Luiza was one of more than 1,000 newborns since October with birth defects that are suspected of links to themosquito-borne Zika virus. Many of the 130 infants in the care of Drs. Chagas and Paschoal may never learn to talk or walk, Dr. Chagas said. Some will have trouble seeing. Many could develop epilepsy. “It’s safe to say almost all of them will require long-term, continual care,” said Edwin Trevathan, professor of neuroscience at Baylor University and a former director of the U.S. Centers for Disease Control and Prevention’s national center on birth defects and developmental disabilities. Breaking the news to new mothers makes the work difficult for doctors. Mothers sometimes arrive for appointments excited because their babies’ heads have grown. Dr. Chagas has the job of telling them the change isn’t a sign of improvement, but a buildup of fluid in the head that must be drained. Dr. Paschoal, a neuropediatric resident, often tries to soften the news, as she did with Maria Luiza’s mother, Eliane Moreira de Carvalho, because it is impossible to know the severity of the birth defects now unfolding. Ms. Carvalho was upbeat after the consultation. “Now, we have to move forward and take care of her,” she said. The young mother said she won’t have more children so she can concentrate her attention on Maria Luiza. Her husband also works in agriculture, and the family gets financial aid from the government to help make ends meet. Maria Luiza has several brain abnormalities: The corpus callosum, which connects the two hemispheres of the brain and communicates between them, didn’t form properly. Her right eye could be impaired, another sign of brain damage. “We’re careful when we talk to them because no one wants to receive this kind of news,” Dr. Paschoal said. After seeing the first few cases last fall, Dr. Paschoal said, she wanted to cry. The 29-year-old medical resident is afraid to have her own children, she said: “I want to have them, but you don’t think about a thing like this.” New risksScientists are trying to understand how a virus that has appeared benign since first identified nearly 70 years ago could now pose such a grave risk. One possibility, they say, is that serious complications went mostly unnoticed as the virus spread from Africa to Asia and the Pacific islands. Infections might have passed largely through poor countries without effective disease tracking, or the outbreaks could have been much smaller, making complications harder to spot. Scientists are also exploring whether mutations developed in the virus that made it more virulent or easily transmissible as it moved around the world. Researchers have looked back at medical records from pregnancies and births during and after a Zika outbreak in French Polynesia that occurred in 2013 and early 2014. They discovered 19 fetuses and newborns with brain abnormalities similar to those now seen in Brazil; six of the babies are alive but severely impaired, said a study published in March. Experts in child development say the Zika virus may trigger other birth defects that won’t be detected until after these babies grow. Ana Gabriela do Prado Paschoal, a neuropediatric resident in Salvador, Brazil. The 29-year-old doctor is afraid to have her own children, she said: ‘I want to have them, but you don’t think about a thing like this.’ PHOTO:LUCIANA MAGALHAES“We do anticipate there would be a spectrum of outcomes,” said Margaret Honein, an epidemiologist on a pregnancy-and-birth-defects task force belonging to the CDC’s Zika response. There could be hidden problems with the brain that don’t show up as microcephaly, for example. Without a vaccine for Zika, public-health authorities are trying to control mosquitoes spreading the virus. They are providing mosquito repellent and, in some places, contraceptives, to women of childbearing age. Outbreaks have been reported for the first time in 42 countries and territories since last year, most in Latin America, according to the World Health Organization. Health officials and experts in Brazil say the epidemic is peaking, with the number of Zika cases expected to fall in coming months. That forecast is based on dengue fever—transmitted by the same Aedes aegypti mosquito—which usually subsides in May as the weather cools for winter in the Southern hemisphere. North of the equator, U.S. officials are preparing for the possible spread of Zika this summer, particularly in the Gulf states. At least 33 pregnant women in the U.S. have been infected. Some have miscarried or their fetuses developed abnormalities. Health officials say large outbreaks in the U.S. are unlikely because of wide use of air conditioning and window screens, as well as disease tracking. The CDC has tallied 388 Zika cases in the U.S. and 503 in U.S. territories, predominantly Puerto Rico. Public health officials worry Brazil could mark the beginning of a wave of infants born with birth defects in Latin America and the Caribbean. Colombia has started reporting cases. The virus has already spread quickly from Paraguay to Mexico. Of particular concern are poor countries that lack advanced health-care services for pregnant women, as well as repellents, window screens and other mosquito protections. Brazil’s government pledged to spend 796 million reais this year, about $225 million, to diagnose and treat babies with microcephaly. Public-health organizations say they will need more. In a small therapy room at the Pedro I municipal hospital in Campina Grande, at the center of the Zika epidemic, a physical therapist placed Nicolas Felipe de Oliveira face up on a large green mat and stretched his stiff legs. Nicolas could lift and move his head a bit. When the therapist stretched him across a big yellow exercise ball, he burst into tears. Nicolas, currently five months old, now lifts his head and smiles, said his grandmother, Ivaneide Matias. He still cries often, she said. Physicians hope early stimulation will minimize the disabilities, said Rogerio Gomes, the coordinator at Instituto Bahiano de Reabilitação in Salvador. In March, the facility started offering therapy to stimulate the Zika babies, using techniques established for other disabilities. Therapists sing songs to the babies and use contrasting patterns to grab their attention. Some of the infants have difficulty making eye contact, the therapists said. The weekly sessions last about 80 minutes, usually attended by three mothers and their babies. They work with a team that includes a psychologist, physical therapist, occupational therapist and speech therapist. “Every week you observe gains,” said therapist Elane Bahia Lemos.“It doesn’t mean that from one week to another, they will be able to hold their heads, it’s a process.” Keeping hopeSilvia Leandra de Jesus Pinheiro says her life has been turned upside down since her daughter Geovanna was born in October with microcephaly. “I was still at the delivery table,” Ms. Pinheiro said, when she learned, though she suspected something was wrong. She had a fever in her seventh month of pregnancy last year. Geneticist Diego Miguel, who saw Geovanna at the end of March, said he was treating her case as Zika-related because she was born during the outbreak and her birth defects fit the pattern. Geovanna’s head measured 29.5 centimeters when she was born, 2 centimeters below normal. The ventricles in her brain are dilated and she has lesions on her frontal lobe, according to scans conducted at birth. Her legs are stiff and she keeps her fists clenched. Clicia Nunes, of the Instituto Bahiano de Reabilitação in Salvador, Brazil, examines Geovanna de Jesus Pinheiro during a recent visit. The baby was born with defects believed to be related to Zika. PHOTO: LUCIANA MAGALHAESMs. Pinheiro, a 33-year-old elementary-school teacher, said she was able to quit her job to take care of her daughter full-time because her husband owns a small business as a cellphone technician. She takes Geovanna to physiotherapy for twice-weekly sessions. The baby’s physicians have told her that Geovanna could have trouble with speech and movement. “I know there will be delays,” she said, “but my hope is that she gets there, even if it’s after other kids her age.” Clicia Nunes Santos Ferreira, a physician who specializes in physical therapy and rehabilitation at the Instituto Bahiano, said she had treated 10 cases of microcephaly over about nine years before the Zika epidemic. “There are some who may develop, but others not,” she said. “This is all very new. We do not know what will become of this generation.” Write to Luciana Magalhaes at [email protected] Betsy McKay at [email protected] http://www.wsj.com/articles/brain-damage-in-zika-babies-is-far-worse-than-doctors-expected-1461859591