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Table IgM against Zika virus and dengue virus in the serum and CSF of neonates with microcephaly, Pernambuco State, Brazil, 2015, by age (days) at testing ELISA values are patient optical densities divided by negative control densities (P/N); values less than 2 were considered negative, 2–3 equivocal, and more than 3 positive. CSF=cerebrospinal fluid. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30253-7/fulltext

ReferencesWHO. WHO Director-General summarizes the outcome of the Emergency Committee regarding clusters of microcephaly and Guillain-Barré syndrome.http://www.who.int/mediacentre/news/statements/2016/emergency-committee-zika-microcephaly/en/; Feb 1, 2016. ((accessed Feb 12, 2016).)View in Article Lanciotti, RS, Kosoy, OL, Janeen, J et al. Genetic and serologic properties of Zika virus associated with an epidemic, Yap State, Micronesia, 2007. Emerg Infect Dis. 2008; 14: 1232View in Article | CrossRef | PubMed | Scopus (69)Carrolla, ID and Toovey, SA. Dengue fever and pregnancy—a review and comment. Travel Med Infect Dis. 2007; 5: 3183View in Article Tunkel, AR, Glaser, CA, Bloch, KC et al. The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2008; 47: 303–327View in Article | CrossRef | PubMed | Scopus (284)

Zika-specific IgM was detected in 30 (97%) of 31 CSF samples and in 28 (90%) of 31 serum samples. One CSF sample tested negative. Monotypic response to Zika virus in the CSF was confirmed by plaque reduction neutralisation test. Since IgM does not cross either the placenta barrier or the blood–brain barrier, the presence of IgM in the CSF indicates that the neonate had the infection in the CNS.3, 4 The finding of Zika-specific IgM in the CSF of those 30 of 31 neonates with brain abnormalities indicates that they had a congenital infection with Zika virus. We believe that this is very strong evidence that the microcephaly was a consequence of Zika virus infection. We declare no competing interests. We thank Laura C Rodrigues and the Microcephaly Epidemic Research Group for their support.

Table IgM against Zika virus and dengue virus in the serum and CSF of neonates with microcephaly, Pernambuco State, Brazil, 2015, by age (days) at testing ELISA values are patient optical densities divided by negative control densities (P/N); values less than 2 were considered negative, 2–3 equivocal, and more than 3 positive. CSF=cerebrospinal fluid.

The epidemic of microcephaly in Brazil has been declared a Public Health Emergency of International Concern by WHO.1 The declaration states that a causal relationship between Zika virus infection during pregnancy and microcephaly is strongly suspected, although not yet scientifically proven.1 The hesitancy to accept causation in the presence of much epidemiological circumstantial evidence is due to the paucity of laboratory confirmation of Zika virus in affected neonates. Here, we report the serological confirmation of Zika virus infection in the CNS of 30 neonates with microcephaly. From Oct 21 to Oct 30, 2015, we collected blood and cerebrospinal fluid (CSF) samples from 31 neonates with microcephaly in the state of Pernambuco, Brazil, most of whom were born between Sept 12 and Oct 27, 2015, in public maternity hospitals. The samples were collected on average 9 days after birth (range 1–40 days; 20 of 31 neonates in the first week after birth). The neonates were kept in hospital while results from brain imaging and laboratory tests were awaited. Serum and CSF samples were tested by RT-PCR or real-time RT-PCR, or both, for Zika, dengue, and chikungunya genomes. Viral RNA was not detected, probably because infections in the mother occurred at least 6 months before giving birth. The 31 samples of CSF and serum were tested for IgM specific for Zika virus using capture ELISA based on the US Centers for Disease Control and Prevention (CDC) Emergency Use Authorization protocol with reagents from Robert Lanciotti (CDC Fort Collins, CO, USA). Simultaneous tests were done for dengue virus to investigate cross-reaction between these two flaviviruses. The ratio of patient optical density to negative control value (P/N) was calculated (table).2

The epidemic of microcephaly in Brazil has been declared a Public Health Emergency of International Concern by WHO.1 The declaration states that a causal relationship between Zika virus infection during pregnancy and microcephaly is strongly suspected, although not yet scientifically proven.1 The hesitancy to accept causation in the presence of much epidemiological circumstantial evidence is due to the paucity of laboratory confirmation of Zika virus in affected neonates. Here, we report the serological confirmation of Zika virus infection in the CNS of 30 neonates with microcephaly.

Marli Tenorio Cordeiro, Lindomar J Pena, Carlos A Brito, Laura H Gil, Ernesto T MarquesPublished Online: 18 April 2016DOI: http://dx.doi.org/10.1016/S0140-6736(16)30253-7

Correspondence Positive IgM for Zika virus in the cerebrospinal fluid of 30 neonates with microcephaly in Brazilhttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30253-7/fulltext

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Pregnant Illinois Woman Tests Positive For Zika VirusApril 18, 2016 4:17 PM By Steve MillerFiled Under: Health, Steve Miller, Zika virus Aedes aegypti mosquitos in various stages of development are displayed at en exhibition on Dengue fever on January 28, 2016 in Recife, Pernambuco state, Brazil. The mosquito transmits the Zika virus, as well as Dengue.(Photo by Mario Tama/Getty Images) 10(CBS) — The Illinois Department of Public Health says another pregnant woman has tested positive for the Zika virus. This latest case means there are now three confirmed cases of Zika among pregnant women in Illinois. Doctors have linked Zika to microcephaly – a birth defect where the head is smaller than normal. Besides the three cases of the virus in pregnant women, six other females also have Zika and four males have it.The Illinois Department of Public Health says all 13 had traveled to other countries. http://chicago.cbslocal.com/2016/04/18/pregnant-illinois-woman-tests-positive-for-zika-virus/

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CDCStatesStatesStatesStatesCDCStatesStatesStatesStates 6-Apr7-Apr8-Apr11-Apr12-Apr13-Apr13-Apr14-Apr15-Apr18-AprAL2333323333AR1222222222AZ1111111111CA29303333332933333434CO2222222222CT1111111111DE3333333333DC3333333333FL78828485858285858686GA11111111111111111113HI5777757777IL10101010101010101013IN6666666666IA4444444444KS1111111111KY3333333333LA4444444444MD6666677888MA7777777777ME1222212222MI2333323333MN12121212121212121212MO2333333333MS2333333333MT1111111111NC8888899999NE2222222222NH2222222222NJ5555588888NM0111101111NV2223323444NY55666666665469696973OH9999999999OK3333333333OR610101010610101010PA12121212121212121215TN1222222222TX27282828282731313232UT2222222222VA8999989111111VT0000000011WA2333323333WV5555555555 346379384386386358397401405417

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Latest Facts and Advisories as of 4/18/2016 [ Español (PDF)]Reported cases of Zika in New York City: 40 Six of the forty cases were pregnant at the time of diagnosis;All cases contracted Zika while visiting other countries; andAll patients have recovered.http://www1.nyc.gov/site/doh/health/health-topics/zika-virus.page

Latest Facts and Advisories as of 4/18/2016 [ Español (PDF)]Reported cases of Zika in New York City: 40 Six of the forty cases were pregnant at the time of diagnosis;All cases contracted Zika while visiting other countries; andAll patients have recovered.

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Zika virus detected in seven B.C. residents, including two pregnant women BY PAMELA FAYERMAN, VANCOUVER SUN APRIL 18, 2016 11:45 PM 1 STORYPHOTOS ( 2 ) This Feb. 12, 2016 photo shows two-week-old Sophia, born with microcephaly, during a physical therapy session at the Pedro I hospital in Campina Grande, Brazil. While some Brazilian health experts believe the outbreak of the Zika virus is linked to the surge in rare birth defects like microcephaly, this city-run hospital is a case in point of government neglect. For example, the mayor's request for $1.5 million to the Health Ministry to buy an MRI scanner has so far gone unmet. As part of across-the-board budget cuts in February, the Health Ministry was down about $650 million of planned spending.Photograph by: Felipe Dana , Vancouver SunSeven B.C. residents have tested positive for the Zika virus, including two pregnant women whose fetuses are now being closely monitored at the BC Women’s Hospital Reproductive Infectious Diseases Clinic. Since testing began in B.C. last November, 635 Zika virus tests have been conducted. But only in the last few days has the most dreaded scenario occurred: positive tests in pregnant women whose fetuses may develop birth defects. Each of the seven cases involved travellers who returned from these Caribbean, Central and South America places: Colombia, El Salvador, Haiti, Dominica and St. Martin. Five of the B.C. residents who have tested positive are women. None of the British Columbians who have been infected have been ill enough to be hospitalized. Indeed, in up to 80 per cent of infections, there are few symptoms. According to the latest update from the federal government (April 14), there have been 46 travel-related cases of Zika in Canada. Another update is due in a few days. There is a proven association between Zika virus infection and babies born with microcephaly (abnormally small heads) and other abnormalities that can limit children’s growth, mental and physical abilities. Dr. David Patrick, an expert in epidemiology and public health at the University of B.C. and B.C. Centre for Disease Control (BCCDC), said in an interview that pregnant, infected women will receive repeat ultrasounds (every three to four weeks) at the hospital to monitor fetal head measurements and other developmental cues. But it is not an exact science, as Patrick and his co-authors have noted in a recent BC Medical Journal article: “Unfortunately, ultrasound cannot reliably detect microcephaly until late in the second trimester and there is no gestational age by which microcephaly can be ruled out.” Dr. Julie van Schalkwyk, head of obstetrics and gynecology at B.C. Women’s Hospital, refused to speak about the two cases being monitored at the hospital. But she said it is an anxiety-provoking issue that keeps her up at night since so little is known about the virus. Doctors don’t know how the virus will affect pregnant women, how likely it is it will infect the fetus, the likelihood of birth defects if the fetus is infected, which stage in development the infection may cause the most harm to fetuses and if sexual transmission poses a different risk of birth defects than mosquito-borne transmission. “It’s a terrible state for us to be in because we have so little information to give patients about the likelihood of their babies becoming infected, and if they do, how this will manifest itself in fetal abnormalities. It really is like being blindfolded,” said van Schalkwyk, who is also a specialist in infectious diseases during pregnancy. “It’s a very distressing situation for doctors and their patients. I don’t know if there’s any analogy in (maternal-fetal) medicine.” Infected, pregnant women can choose to have an abortion up to 23 weeks plus six days gestation. Pregnant women do not have to have any symptoms of Zika to get tested; they must merely demonstrate they were in an area where they might have been exposed to the virus. B.C. experts say women who are pregnant or trying to get pregnant should think about postponing travel to areas where Zika is circulating. The Public Health Agency of Canada recommends that women coming back from such areas should delay getting pregnant for at least two months. And since Zika can persist in semen for more than two months, abstinence from intercourse or strict adherence to proper use of condoms for several months is advised by experts. Manitoba public health officials recently recommended condoms or abstinence for at least six months among men who have travelled to an area of risk, who have symptoms of the virus or are diagnosed with it. Public health experts recommend infected men with partners who are pregnant or may become pregnant use condoms throughout the duration of pregnancy. “If you want to play it 100-per-cent safe, wait a few months (after travel) before conceiving because the virus can hang around in the body, in semen, for example,” Patrick said. Patrick said doctors can refer travellers returning from Zika-transmission areas to laboratories for blood and urine collection if they have two or more symptoms within two weeks of their return. Samples are then tested at the BCCDC lab. In the winter months, when so many B.C. residents were travelling south to sunnier locations, as many as 80 tests were being carried out per week in this province. That number has now tapered off to about 30 a week. Patrick said the trends so far show that women are four times more likely to get tested because of pregnancy concerns. “We’ve seen no evidence to this point that women are more susceptible (to getting infected),” he said, adding that early signs are that pregnant women who have no symptoms appear to have a lower risk of having babies with congenital defects. While many thousands of people in countries like Brazil have already been infected, and such people develop immunity for an undetermined duration, as Patrick points out, “Zika is still going to be around for a long time,” so endemic countries can’t let up on mosquito control efforts, nor should travellers when it comes to avoiding mosquito bites. Sun Health Issues Reporter [email protected] Zika virus is transmitted through the bite of one type of mosquito — Aedes — which also transmits dengue fever and chikungunya. To date, the Aedes mosquito has never been detected in Canada; only in tropical, subtropical and temperate regions. As of last week, about 30 U.S. states reported detection the mosquito. There have also been some cases of transmission through sexual contact and blood transfusions. Until 2007, infection in humans was rare and restricted to Africa and Asia. The first western hemisphere case was reported in 2015. Only about a quarter of those infected with Zika develop symptoms, which can include fever, joint pain, muscular pain, rash, conjunctivitis and headaches. The incubation period for Zika is three to 12 days and the illness resolves within about a week. There is no preventive vaccine or specific treatment for the Zika virus. Source: BC Medical Journal

Seven B.C. residents have tested positive for the Zika virus, including two pregnant women whose fetuses are now being closely monitored at the BC Women’s Hospital Reproductive Infectious Diseases Clinic. Since testing began in B.C. last November, 635 Zika virus tests have been conducted. But only in the last few days has the most dreaded scenario occurred: positive tests in pregnant women whose fetuses may develop birth defects. Each of the seven cases involved travellers who returned from these Caribbean, Central and South America places: Colombia, El Salvador, Haiti, Dominica and St. Martin. Five of the B.C. residents who have tested positive are women. None of the British Columbians who have been infected have been ill enough to be hospitalized. Indeed, in up to 80 per cent of infections, there are few symptoms. http://www.theprovince.com/health/zika+virus+detected+seven+residents+including+pregnant+women/11861205/story.html

Zika Virus – April 18, 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

April 18, 2016 DEPARTMENT OF HEALTH DAILY ZIKA UPDATE: NO NEW 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 no new cases today. Of the cases confirmed in Florida, five cases are still exhibiting symptoms. According to the CDC, symptoms associated with the Zika virus last between seven to 10 days. Based on CDC guidance, several pregnant women who have traveled to countries with local-transmission of Zika have received antibody testing, and of those, five have tested positive for the Zika virus. The CDC recommends that a pregnant woman with a history of Zika virus and her provider should consider additional ultrasounds. It is recommended that women who are pregnant or thinking of becoming pregnant postpone travel to Zika affected areas. County Number of Cases (all travel related) Alachua 4 Brevard 2 Broward 13 Clay 1 Collier 1 Hillsborough 3 Lee 4 Miami-Dade 36 Orange 5 Osceola 4 Palm Beach 4 Polk 3 Santa Rosa 1 Seminole 1 St. Johns 1 Cases involving pregnant women* 5 Total 88 *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 1,436 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 15 counties included in the declaration– Alachua, Brevard, Broward, Clay, Collier, Hillsborough, Lee, Miami-Dade, Orange, Osceola, Palm Beach, Polk, Santa Rosa, Seminole and St. Johns – 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 the 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.Florida currently has the capacity to test 6,697 people for active Zika virus and 1,537 for Zika antibodies.Federal Guidance on Zika: According to the 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.The CDC has put out guidance related to the sexual transmission of the Zika virus. This includes the 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. http://www.floridahealth.gov/newsroom/2016/04/041816-zika-update.html

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Pennsylvania Blood Tests Submitted for Zika Testing as of April 18, 2016 Information updated Mondays at 2 p.m.CDC Confirmed Cases: 15Pending Test Results: 120http://www.health.pa.gov/My Health/Diseases and Conditions/U-Z/Pages/Zika.aspx#.VxUro_krLZb

Allegheny County Residents Approved for Zika Testing: 67 CDC Confirmed Cases: 1(as of April 18)

Pennsylvania Blood Tests Submitted for Zika Testing as of April 18, 2016 Information updated Mondays at 2 p.m.CDC Confirmed Cases: 15Pending Test Results: 120

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