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SummaryWhat is already known about this topic? Zika virus transmission in Puerto Rico has been ongoing, with the first patient reporting symptom onset in November 2015. Zika virus infection is a cause of microcephaly and other severe birth defects. Zika virus infection has also been associated with Guillain-Barré syndrome. What is added by this report? During November 1, 2015–April 14, 2016, a total of 6,157 specimens from suspected Zika virus–infected patients from Puerto Rico were evaluated and 683 (11%) had laboratory evidence of current or recent Zika virus infection. The public health response includes increased capacity to test for Zika virus, preventing infection in pregnant women, monitoring infected pregnant women and their fetus for adverse outcomes, controlling mosquitos, and assuring the safety of blood products. What are the implications for public health practice? Residents of and travelers to Puerto Rico should continue to employ mosquito bite avoidance behaviors, take precautions to reduce the risk for sexual transmission, and seek medical care for any acute illness with rash or fever. Clinicians who suspect Zika virus disease in patients who reside in or have recently returned from areas with ongoing Zika virus transmission should report cases to public health officials.

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