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Health Officials: Second Zika Case Reported in MississippiMarch 25, 2016 Jackson, Miss. Today the Mississippi State Department of Health (MSDH) reports its second case of Zika virus. The case was in a Noxubee County resident who recently traveled to Haiti. The first case was reported yesterday in a Madison County resident who had traveled to Haiti. Zika is a mosquito-borne virus that may cause devastating birth defects if contracted during pregnancy. Zika virus infection can cause a mild illness with symptoms (fever, joint pain, conjunctivitis or rash) lasting for several days to a week, but 80 percent of those infected show no symptoms at all. Death is very rare. Zika has been seen in parts of Africa, Southeast Asia, and some Pacific islands for years, but has recently been reported in approximately 30 countries, mostly in the Caribbean, Central, and South America. The Zika virus is spread through the bite of an infected mosquito. The breed of mosquito that is spreading Zika – Aedes Aegypti – has not been detected in Mississippi since the mid-1980s. The MSDH is currently conducting surveillance on all mosquito populations in the state. Pregnant women or women who may get pregnant in the near future should avoid travel to countries with Zika transmission. Pregnant women should avoid sexual contact – or only have protected sex using a condom – with any male who has recently returned from a country with Zika virus. These precautions should continue for the duration of the pregnancy. So far, six cases have been confirmed from sex between an infected male and his female partner. "Pregnant women should avoid travel to these countries," said State Epidemiologist Dr. Thomas Dobbs. "At this time, the mosquito spreading Zika in Mexico, South America and the Caribbean is not known to be present in Mississippi." "Three U.S. territories and 36 other states have already reported travel-associated cases," Dobbs said. "With late spring and summer approaching, we know it is a popular time for mission trips and vacations to these areas. Please be especially mindful of protecting yourself from mosquitoes while you’re abroad. Simple steps can make a big difference." The MSDH advises that precautions should be taken by all travelers to countries with Zika outbreaks. Precautions for travelers include basic protective measures against mosquito-borne illnesses such as using a recommended mosquito repellent that contains DEET while you are outdoors, avoiding areas where mosquitoes are prevalent, and wearing loose, light-colored clothing to cover the arms and legs when outdoors during the day or night. Travelers recently returning from countries with ongoing Zika transmission should take special precautions to avoid mosquito bites in Mississippi to avoid transmitting the virus to local mosquitoes. Precautions should continue for three weeks. There are no available treatments or vaccines for Zika virus. "The MSDH is working with medical partners across the state to ensure that the most current national guidelines for preventing and testing for Zika are being followed," said Dr. Dobbs. "The MSDH Public Health Laboratory now has the ability to test for Zika in-house to allow for rapid turnaround and high volume testing should the need arise." For more information on Zika or other mosquito-borne illnesses, visit www.HealthyMS.com/Zika.Follow MSDH by e-mail and social media at HealthyMS.com/connect. Press Contact: MSDH Office of Communications, (601) 576-7667 Note to media: After hours or during emergencies, call 1-866-HLTHY4U (1-866-458-4948) http://msdh.ms.gov/msdhsite/_static/23,17456,341.html

New tally page http://msdh.ms.gov/msdhsite/_static/14,17454,93,589.html Updated March 25, 2016 This county-by-county report shows human cases and other data currently reported to MSDH. WNV human cases and WNV-positive horses, mosquito samples and blood donors are indications that WNV is circulating in the state. All residents, regardless of county of residence, should take precautions to prevent WNV infection. Human Cases of Mosquito-Borne IllnessesWNV Testing WNVChikungunyaZikaOther1DeathsPositive Mosquito Samples2Positive Blood Donors3Total:00200000Adams00000 0Alcorn00000 0Amite00000 0Attala00000 0Benton00000 0Bolivar00000 0Calhoun00000 0Carroll00000 0Chickasaw00000 0Choctaw00000 0Claiborne00000 0Clarke00000 0Clay00000 0Coahoma00000 0Copiah00000 0Covington00000 0DeSoto00000 0Forrest0000000Franklin00000 0George00000 0Greene00000 0Grenada00000 0Hancock00000 0Harrison00000 0Hinds0000000Holmes00000 0Humphreys00000 0Issaquena00000 0Itawamba00000 0Jackson00000 0Jasper00000 0Jefferson00000 0Jefferson Davis00000 0Jones00000 0Kemper00000 0Lafayette00000 0Lamar00000 0Lauderdale00000 0Lawrence00000 0Leake00000 0Lee00000 0Leflore00000 0Lincoln00000 0Lowndes00000 0Madison00100 0Marion00000 0Marshall00000 0Monroe00000 0Montgomery00000 0Neshoba00000 0Newton00000 0Noxubee00100 0Oktibbeha00000 0Panola00000 0Pearl River00000 0Perry00000 0Pike00000 0Pontotoc00000 0Prentiss00000 0Quitman00000 0Rankin00000 0Scott00000 0Sharkey00000 0Simpson00000 0Smith00000 0Stone00000 0Sunflower00000 0Tallahatchie00000 0Tate00000 0Tippah00000 0Tishomingo00000 0Tunica00000 0Union00000 0Walthall00000 0Warren00000 0Washington00000 0Wayne00000 0Webster00000 0Wilkinson00000 0Winston00000 0Yalobusha00000 0Yazoo0000 0Unspecified County00000 0Human case count represents only those confirmed by laboratory testing. 1 Other mosquito-borne illnesses include La Crosse encephalitis, St. Louis encephalitis, and Eastern Equine encephalitis. Humans as well as horses can be infected with mosquito-borne illnesses, and infected horses indicate that humans may also be at risk. More about these diseases » 2 Mosquito are trapped and tested for West Nile virus (WNV) in selected counties where a higher number of human cases have occurred in previous years. WNV positive mosquitoes indicate that WNV is circulating in the state, and that all residents, regardless of location, should take precautions. 3 Infected blood donors are identified through routine screening to ensure the safety of transfusion products. WNV-positive blood donors who are symptomatic are included in the WNV human case count.

A second Zika virus case has been reported in Mississippi, according to the Mississippi Department of Health. The patient is from Noxubee, Mississippi and recently traveled to Haiti, according to a press release issued by MSDH Friday morning. http://www.clarionledger.com/story/news/2016/03/25/second-zika-case-reported-ms/82249078/

DoH contact seems to be wrong: A second Zika virus case has been reported in Mississippi, according to the Mississippi Department of Health. The patient is from Noxubee, Mississippi and recently traveled to Haiti, according to a press release issued by MSDH Friday morning. http://www.clarionledger.com/story/news/2016/03/25/second-zika-case-reported-ms/82249078/

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March 25, 2016 DEPARTMENT OF HEALTH DAILY ZIKA UPDATE: TWO NEW TRAVEL-RELATED CASES TODAY IN CLAY AND COLLIER COUNTIES 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 two new travel-associated cases today with one in Collier County and one in Clay County. Both Collier and Clay counties have been added to the Declaration of Public Health Emergency. 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, four 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 11 Clay 1 Collier 1 Hillsborough 3 Lee 3 Miami-Dade 32 Orange 5 Osceola 4 Polk 2 Santa Rosa 1 Seminole 1 St. Johns 1 Cases involving pregnant women* 4 Total 75 *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 1,165 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.The Declaration currently includes the 14 affected counties – Alachua, Brevard, Broward, Clay, Collier, Hillsborough, Lee, Miami-Dade, Orange, Osceola, 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.Florida currently has the capacity to test 4,101 people for active Zika virus and 1,727 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 are examining a possible link between the virus and harm to unborn babies exposed during pregnancy.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 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/2016/03/032516-zika-update.html

County Number of Cases (all travel related) Alachua 4 Brevard 2 Broward 11 Clay 1 Collier 1 Hillsborough 3 Lee 3 Miami-Dade 32 Orange 5 Osceola 4 Polk 2 Santa Rosa 1 Seminole 1 St. Johns 1 Cases involving pregnant women* 4 Total 75

Estimating Contraceptive Needs and Increasing Access to Contraception in Response to the Zika Virus Disease Outbreak — Puerto Rico, 2016Early Release / March 25, 2016 / 65 http://www.cdc.gov/mmwr/volumes/65/wr/mm6512e1er.htm?s_cid=mm6512e1er_w

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Zika virus outbreak on Yap Island, Federated States of Micronesia. N Engl J Med 2009;360:2536–43. CrossRef PubMedCalvet G, Aguiar RS, Melo AS, et al. Detection and sequencing of Zika virus from amniotic fluid of fetuses with microcephaly in Brazil: a case study. Lancet Infect Dis 2016;S1473-3099(16)00095-5 Published online February 17, 2016. CrossRef PubMedMlakar J, Korva M, Tul N, et al. Zika virus associated with micrcephaly. N Engl J Med 2016;374:951–8. CrossRef PubMedMartines RB, Bhatnagar J, Keating MK, et al. Notes from the field: evidence of Zika virus infection in brain and placental tissues from two congenitally infected newborns and two fetal losses—Brazil, 2015. MMWR Morb Mortal Wkly Rep 2016;65:159–60. CrossRef PubMedMeaney-Delman D, Hills SL, Williams C, et al. Zika virus infection among US pregnant travelers—August 2015–February 2016. MMWR Morb Mortal Wkly Rep 2016;65:211–4. CrossRefPubMedBrasil P, Pereira JP , Raja Gabaglia C, et al. 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BOX. Recommendations for counseling persons in areas of active Zika virus transmission interested in attempting conceptionAssess risk of Zika virus exposureEnvironment Air conditioning, window screens in home Work environment Residence in area with high mosquito density Level of Zika virus transmission in the local area Personal measures to prevent mosquito bites Protective clothing Use of EPA-registered insect repellent Emptying/removing standing water in containers Personal measures to prevent sexual transmission Willingness to use condoms or abstain from sex throughout pregnancy Discuss Zika virus infection in pregnancySigns/symptoms of Zika virus disease Possible adverse consequences of Zika virus infection during pregnancy Unknown duration of epidemic Explore reproductive life planFertility Age Reproductive history Medical history Personal values, preferences Discuss risks/benefits of pregnancy at this time with woman and her partnerIf pregnancy not desired now, discuss contraceptive options Top FIGURE 1. Updated interim guidance: testing algorithm*,†,§,¶ for a pregnant woman with possible Zika virus exposure,** not residing in an area with active Zika virus transmission * Testing is recommended for pregnant women with clinical illness consistent with Zika virus disease, including one or more of the following signs or symptoms: acute onset of fever, rash, arthralgia, or conjunctivitis during or within 2 weeks of travel or possible sexual exposure. Testing includes Zika virus reverse transcription-polymerase chain reaction (RT-PCR), and Zika virus immunoglobulin M (IgM) and neutralizing antibodies on serum specimens. More information is available at http://www.aphl.org/Materials/CDCMemo_Zika_Chik_Deng_Testing_011916.pdf. Because of the overlap of symptoms and areas where other viral illnesses are endemic, evaluate for possible dengue or chikungunya virus infection. † Testing can be offered to pregnant women without clinical illness consistent with Zika virus disease. If performed, testing should include Zika virus IgM, and if IgM test result is positive or indeterminate, neutralizing antibodies on serum specimens. Testing should be performed 2–12 weeks after travel. § Laboratory evidence of maternal Zika virus infection: 1) Zika virus RNA detected by RT-PCR in any clinical specimen; or 2) positive Zika virus IgM with confirmatory neutralizing antibody titers that are ≥4-fold higher than dengue virus neutralizing antibody titers in serum. Testing is considered inconclusive if Zika virus neutralizing antibody titers are <4-fold higher than dengue virus neutralizing antibody titers. ¶ Fetal abnormalities consistent with Zika virus disease include microcephaly, intracranial calcifications, and brain and eye abnormalities. Fetal ultrasounds might not detect abnormalities until late second or early third trimester of pregnancy. ** Possible exposure to Zika virus includes travel to an area with active Zika virus transmission (http://wwwnc.cdc.gov/travel/notices/), or sex (vaginal intercourse, anal intercourse, or fellatio) without a condom with a man who traveled to, or resided in, an area with active Zika virus transmission. Testing is not currently recommended for pregnant women with possible sexual exposure to Zika virus if both partners are asymptomatic. Top FIGURE 2. Updated interim guidance: testing algorithm*,†,§,¶ for a pregnant women residing in an area with active Zika virus transmission,** with or without clinical illness †† consistent with Zika virus disease * Tests for pregnant women with clinical illness consistent with Zika virus disease include Zika virus reverse transcription-polymerase chain reaction (RT-PCR), and Zika virus immunoglobulin M (IgM) and neutralizing antibodies on serum specimens. More information is available at http://www.aphl.org/Materials/CDCMemo_Zika_Chik_Deng_Testing_011916.pdf. Because of the overlap of symptoms and areas where other viral illnesses are endemic, evaluate for possible dengue or chikungunya virus infection. If chikungunya or dengue virus RNA is detected, treat in accordance with existing guidelines. Timely recognition and supportive treatment for dengue virus infections can substantially lower the risk of medical complications and death. Repeat Zika virus testing during pregnancy is warranted if clinical illness consistent with Zika virus disease develops later in pregnancy. † Testing can be offered to pregnant women without clinical illness consistent with Zika virus disease. If performed, testing should include Zika virus IgM, and if IgM test result is positive or indeterminate, neutralizing antibodies on serum specimens. Results from serologic testing are challenging to interpret in areas where residents have had previous exposure to other flaviviruses (e.g., dengue, yellow fever) because of cross-reactivity with other flaviviruses. § Laboratory evidence of maternal Zika virus infection: 1) Zika virus RNA detected by RT-PCR in any clinical specimen; or 2) positive Zika virus IgM with confirmatory neutralizing antibody titers that are ≥4-fold higher than dengue virus neutralizing antibody titers in serum. Testing would be considered inconclusive if Zika virus neutralizing antibody titers are <4-fold higher than dengue virus neutralizing antibody titer. ¶ Fetal abnormalities consistent with Zika virus disease include microcephaly, intracranial calcifications, and brain and eye abnormalities. Fetal ultrasounds might not detect abnormalities until late second or early third trimester of pregnancy. ** http://wwwnc.cdc.gov/travel/notices/. Local health officials should determine when to implement testing of asymptomatic pregnant women based on information about levels of Zika virus transmission and laboratory capacity. †† Clinical illness is consistent with Zika virus disease if one or more signs or symptoms (acute onset of fever, rash, arthralgia, or conjunctivitis) are present.

CDC has updated its interim guidance for U.S. health care providers caring for women of reproductive age with possible Zika virus exposure (1) to include recommendations on counseling women and men with possible Zika virus exposure who are interested in conceiving. This guidance is based on limited available data on persistence of Zika virus RNA in blood and semen (2–5). Women who have Zika virus disease* should wait at least 8 weeks after symptom onset to attempt conception, and men with Zika virus disease should wait at least 6 months after symptom onset to attempt conception. Women and men with possible exposure to Zika virus but without clinical illness consistent with Zika virus disease should wait at least 8 weeks after exposure to attempt conception. Possible exposure to Zika virus is defined as travel to or residence in an area of active Zika virus transmission (http://www.cdc.gov/zika/geo/active-countries.html), or sex (vaginal intercourse, anal intercourse, or fellatio) without a condom with a man who traveled to or resided in an area of active transmission. Women and men who reside in areas of active Zika virus transmission should talk with their health care provider about attempting conception. This guidance also provides updated recommendations on testing of pregnant women with possible Zika virus exposure. These recommendations will be updated when additional data become available. The current Zika virus outbreak was identified in Brazil in May 2015, and knowledge about Zika virus infection, its potential adverse effects on pregnancy, and transmission is rapidly evolving. As of March 23, 2016, there were 39 countries and U.S. territories reporting active Zika virus transmission (6). Updates on areas with active Zika virus transmission are available online athttp://wwwnc.cdc.gov/travel/notices. Zika virus is primarily transmitted through the bite of infected Aedes species mosquitoes. However, Zika virus can also be sexually transmitted from a man infected with the virus to his sexual partners (3,5,7–10). Based on data from a previous outbreak, most persons infected with Zika virus are asymptomatic (11). Signs and symptoms, when present, are typically mild, with the most common being acute onset of fever, macular or papular rash, arthralgia, and conjunctivitis (11). Increasing epidemiologic, clinical, laboratory, and pathologic evidence supports a link between Zika virus infection during pregnancy and adverse pregnancy and birth outcomes, including pregnancy loss, microcephaly, and brain and eye abnormalities (12–16). A critical knowledge gap for health care providers counseling women is the level of risk for adverse pregnancy and birth outcomes associated with Zika virus infection. That risk is currently unknown, but two recent studies might be informative. A retrospective analysis of the 2013–2014 Zika virus outbreak in French Polynesia identified eight fetuses and infants with microcephaly; using mathematical modeling, it was estimated that microcephaly affected approximately 1% of fetuses or infants born to women infected with Zika virus during the first trimester of pregnancy (17). In a recent study from Brazil, among 42 women with laboratory-confirmed Zika virus infection at any time during pregnancy who underwent prenatal ultrasonographic studies, 12 (29%) had abnormal findings; these included microcephaly, intracranial calcifications, other brain abnormalities, abnormal cerebral artery flow, intrauterine growth restriction, and fetal death (16). Further studies are underway to better estimate this risk but it is important to recognize that microcephaly caused by viral destruction of brain tissue is likely to be part of a spectrum of neurological damage; the percentages in both studies may substantially underestimate the proportion of infants affected. The risk for adverse pregnancy outcomes associated with maternal Zika virus infection around the time of conception is currently unknown. However, early reports suggest there might be adverse outcomes associated with Zika virus infection in early pregnancy: two women with Zika virus disease at <7 weeks’ gestation both had pregnancy losses, with Zika virus RNA detected in products of conception, and another woman with clinical illness consistent with Zika virus disease at 7–8 weeks’ gestation delivered a full-term infant with severe microcephaly (15). Other viral infections (e.g., cytomegalovirus, rubella, and parvovirus) that have occurred around the time of conception have been associated with congenital infection and associated adverse pregnancy and birth outcomes (18–22); however, in these cases the exact timing of infection relative to timing of conception was often unknown. Because currently available data are limited, providing preconception counseling following possible Zika virus exposure is challenging. Decisions about pregnancy timing are personal and complex, and discussions with patients should be individualized. CDC and state health departments have received numerous inquiries from health care providers requesting information on how best to counsel patients regarding timing of pregnancy following possible Zika virus exposure and diagnosis of Zika virus disease. CDC has developed updated interim guidance to address these concerns. This guidance is based on expert opinion, the limited available data on Zika virus, and knowledge about risks for other viral infections in the periconceptional period. CDC continues to evaluate all available evidence and to update recommendations as new information becomes available. Top Preconception Counseling Recommendations For Women With Possible Exposure to Zika Virus Who Do Not Reside In an Area With Active Zika Virus TransmissionThere is no evidence that Zika virus will cause congenital infection in pregnancies conceived after the resolution of maternal Zika viremia. Data on the incubation period for Zika virus disease and the duration of Zika viremia are limited. Evidence from case reports and experience from related flavivirus infections indicate that the incubation period for Zika virus disease is likely 3–14 days (7,23,24). After symptom onset, the duration of Zika viremia may range from a few days to 1 week (24–26); the longest duration of viremia in the published literature was 11 days (4). Health care providers should provide preconception counseling to women with possible Zika virus exposure. Discussions should include information about the signs and symptoms of Zika virus disease and the potential adverse outcomes associated with Zika virus infection in pregnancy. Women with Zika virus disease should wait until at least 8 weeks after symptom onset before attempting conception. No data are available regarding the risk for congenital infection among pregnant women with asymptomatic infection. Based on the estimated upper limit of the incubation period for Zika virus disease (14 days) and approximate tripling of the longest published period of viremia after symptom onset (11 days), and given the limited data on duration of Zika viremia and the potential for individual immune system variability, asymptomatic women with possible Zika virus exposure should be advised to wait at least 8 weeks after the last date of exposure before attempting conception. Health care providers should provide information on available strategies to prevent unintended pregnancy, including use of the most effective contraceptive methods that can be used correctly and consistently (27). In addition, patients should be counseled that correct and consistent use of condoms reduces the risk for sexually transmitted infections. Top Preconception Counseling Recommendations For Men With Possible Exposure to Zika Virus Who Do Not Reside In an Area With Active Zika Virus TransmissionSexual transmission of Zika virus can occur, although data about the risk are limited. CDC has reported six laboratory-confirmed cases of sexually transmitted Zika virus disease (9,28). To date, all reported cases have involved sexual transmission from a man with symptoms, and have occurred within 3 weeks of symptom onset (7,9,10). Infectious Zika virus has been isolated from the semen of two men (one with hematospermia) at least 2 weeks after symptom onset (5) and possibly up to 10 weeks after symptom onset (3). A third report documented Zika virus RNA in semen 62 days after symptom onset (2). The duration and pattern of Zika virus persistence in semen is not known; further testing was not performed to document when replicative Zika virus or Zika virus RNA were no longer present in the men’s semen. Based on these data, men and their female partners should wait to attempt conception until the risk for sexual transmission is believed to be minimal. Men who have had a diagnosis of Zika virus disease should wait at least 6 months after symptom onset before attempting conception. This interval was recommended based on limited information regarding persistence of Zika virus in semen, and it allows for three times the longest period that Zika virus RNA has been detected in semen after symptom onset. It is not known whether men with asymptomatic Zika virus infection can transmit the virus sexually. There have been no reported cases of sexual transmission from asymptomatic men. Although it has not been documented, it is biologically plausible that men who have been infected with Zika virus but display no symptoms of Zika virus disease might shed Zika virus in the semen. In the absence of data and to be consistent with other recommendations, men who have possible Zika virus exposure without clinical illness consistent with Zika virus disease should wait at least 8 weeks after possible exposure before attempting conception. If symptoms do not develop, the couple could consider attempting conception or waiting longer. Given the limited data, health care providers should discuss with couples the many factors that might influence a decision about attempting conception, such as level of risk for Zika virus exposure and reproductive life plans. Top Preconception Counseling Recommendations For Women and Their Partners Residing In Areas With Active Zika Virus TransmissionHealth care providers caring for women and men residing in areas with active Zika virus transmission who have Zika virus disease should recommend they wait until the risk for viremia or viral shedding in semen is believed to be minimal to avoid potential adverse outcomes that have been linked with Zika virus infection in pregnancy. Women with Zika virus disease should wait at least 8 weeks from symptom onset before attempting conception; men with Zika virus disease should wait at least 6 months from symptom onset before attempting conception. Women and men who reside in an area with active Zika virus transmission, but who do not have clinical illness consistent with Zika virus disease and who desire pregnancy should talk with their health care providers. Particularly in the context of Zika virus transmission, it is important for women and their partners to plan their pregnancies. As part of that planning process, women and their partners should discuss the risks for active Zika virus transmission with their health care providers, and providers should discuss their patients’ reproductive life plans in the context of potential Zika virus exposure (Box). An assessment of the risk for Zika virus exposure includes evaluating the presence of mosquitoes in and around the home, protective measures practiced, and levels of active Zika virus transmission. Taking protective measures to avoid mosquito bites has been demonstrated to reduce the risk for mosquito-borne diseases (29,30); however, it might not be possible to eliminate the risk for Zika virus exposure during pregnancy. The expected duration of a Zika virus outbreak in any particular location is unknown. Health care providers should discuss factors that might influence timing of pregnancy, including fertility, age, reproductive history, medical history, and personal values and preferences. The decision about timing of pregnancy should be made by the woman or couple in consultation with a health care provider. As part of counseling with health care providers, some women and their partners residing in areas of active Zika virus transmission might decide to delay pregnancy. Health care providers should discuss strategies to prevent unintended pregnancy, including use of the most effective contraceptive methods (27). In addition, patients should be counseled that correct and consistent use of condoms reduces the risk for sexually transmitted infections. Top Recommendations For Testing of Persons Attempting ConceptionTesting of serum for evidence of Zika virus infection should be performed in persons with possible exposure to Zika virus who have one or more of the following signs or symptoms within 2 weeks of possible exposure: acute onset of fever, rash, arthralgia, or conjunctivitis (31). Routine testing is not currently recommended for women or men who are attempting conception who have possible exposure to Zika virus but no clinical illness. The performance of the test in asymptomatic persons is unknown, and results might be difficult to interpret. It is not known whether a positive serologic test result in an asymptomatic man would indicate possible presence of Zika virus in semen, or if a negative serologic test result would preclude the presence of the virus in semen. Reverse transcription-polymerase chain reaction (RT-PCR) testing of semen has not yet been validated. Intermittent shedding of other viruses in semen is recognized (32,33); however, the pattern of Zika virus shedding in semen is unknown. Further, the detection of Zika virus RNA in semen does not necessarily indicate the presence of infectious virus in semen. Because of these concerns, a positive or negative semen test result might not provide sufficient data to guide recommendations regarding attempting conception. Thus, testing of semen is not currently recommended. Studies are underway to better understand the performance of these tests, the persistence of Zika virus in semen, and how best to interpret the results. Top Special Considerations For Women Undergoing Fertility TreatmentNo instances of Zika virus transmission during fertility treatment have been documented, but transmission through donated gametes or embryos is theoretically possible, given that Zika virus can be present in semen, and sexual transmission has occurred (2,7–9). Zika virus is not likely to be destroyed in the cryopreservation process. Fertility treatment for sexually intimate couples using their own gametes and embryos should follow the timing recommendations for persons attempting conception, although recommendations might need to be adjusted depending on individual circumstances. The Food and Drug Administration (FDA) has developed guidance for donated tissues in the context of a Zika virus outbreak, including donated sperm, oocytes, and embryos (34); the guidance states that living donors will be deemed ineligible for anonymous donation if they have any of the following risk factors: medical diagnosis of Zika virus infection in the past 6 months; residence in or travel to an area with active Zika virus transmission within the past 6 months; or within the past 6 months had sex with a male partner who, during the 6 months before this sexual contact, received a diagnosis of or experienced an illness consistent with Zika virus disease, or had traveled to an area of active Zika virus transmission. FDA guidance applies to anonymous donors, but does not apply to sexually intimate couples. In accordance with previous FDA guidance, directed (or known) donors must undergo the same evaluation and eligibility determination as anonymous donors. However, gametes or embryos from directed donors who are ineligible may be used, per FDA guidance, if the tissue is properly labeled to indicate potential increased risk, all participating parties are aware of and willing to incur the risk, and physicians are aware of the status of gametes or embryos. Professional organizations recommend recipients be informed and counseled about potential risks before use of the donated tissue (35). Top Updated Recommendations For Testing Pregnant Women With Possible Zika Virus ExposurePregnant women who had possible exposure to Zika virus who do not reside in an area with active transmission should be evaluated for Zika virus infection and tested in accordance with CDC Updated Interim Guidance (Figure 1). Similarly, pregnant women who reside in an area with active Zika virus transmission should be evaluated and tested in accordance with CDC interim guidance (Figure 2); a decision to implement testing of asymptomatic pregnant women should be made by local health officials based on information about levels of Zika virus transmission and laboratory capacity. A negative immunoglobulin M test result obtained 2–12 weeks after known exposure would suggest that a recent Zika virus infection did not occur and could obviate the need for serial ultrasounds. Health care providers should assess their patients’ travel histories. In certain circumstances, such as patients with frequent travel (e.g., daily or weekly) to areas of active Zika virus transmission, health care providers should follow CDC’s interim guidance for pregnant women residing in areas with active Zika virus transmission (Figure 2). Health care providers who care for pregnant women who reside along the U.S.-Mexico border should assess their patients’ travel histories, including frequency of cross-border travel, and destinations. Areas of active Zika virus transmission in Mexico not bordering the United States have been reported. There are currently no reports of active Zika virus transmission along the U.S.-Mexico border. However, if active transmission occurs, local health officials should determine when to implement testing of asymptomatic pregnant women based on information about levels of Zika virus transmission and laboratory capacity. As previously recommended (8), men who travel to or reside in an area with active Zika virus transmission and have a pregnant partner should correctly and consistently use condoms or abstain from sex for the duration of pregnancy. This course is the best way to avoid even a minimal risk for sexual transmission of Zika virus, which could result in adverse fetal effects if contracted during pregnancy. Pregnant women who have had sex without a condom with a male partner with possible Zika virus exposure should be tested for evidence of Zika virus infection if the woman develops at least one sign or symptom of Zika virus disease or if her male partner has had diagnosed Zika virus disease or a clinical illness consistent with Zika virus disease. Pregnant women who do not reside in areas with active Zika virus transmission who have had possible Zika virus exposure during the 8 weeks before conception (6 weeks before the last menstrual period) can be offered serologic testing within 2–12 weeks of this exposure. As previously recommended, all persons with possible exposure and clinical illness consistent with Zika virus disease should be tested for Zika virus infection. An additional update to previously published guidance relates to amniocentesis. Consideration of amniocentesis should be individualized for each clinical circumstance; thus, amniocentesis has been removed from the updated testing algorithms (Figure 1) (Figure 2). Similar to evaluation of other congenital infections, amniocentesis may be considered in the evaluation of potential Zika virus infection. It is unknown how sensitive or specific RT-PCR testing of amniotic fluid is for congenital Zika virus infection, whether a positive result is predictive of a subsequent fetal abnormality, and if it is predictive, what proportion of infants born following infection will have abnormalities. The optimal time to perform amniocentesis to diagnose congenital Zika virus infection is not known; Zika virus RNA has been detected in amniotic fluid as early as 4 weeks after maternal symptom onset, and as early as 17 weeks’ gestation (unpublished data). Health care providers should discuss the risks and benefits of amniocentesis with their patients. The algorithms have also been updated to reflect accumulated data on ultrasonographic findings that might be consistent with Zika virus disease, including microcephaly, intracranial calcifications, and brain and eye abnormalities. This guidance will be updated as additional information becomes available (http://www.cdc.gov/zika/).

Emily E. Petersen, MD1; Kara N.D. Polen, MPH2; Dana Meaney-Delman, MD3; Sascha R. Ellington, MSPH1; Titilope Oduyebo, MD1,4; Amanda Cohn, MD5; Alexandra M. Oster, MD6; Kate Russell, MD4,7; Jennifer F. Kawwass, MD1,8; Mateusz P. Karwowski, MD4,9; Ann M. Powers, PhD10; Jeanne Bertolli, PhD6; John T. Brooks, MD6; Dmitry Kissin, MD1; Julie Villanueva, PhD11; Jorge Muñoz-Jordan, PhD10; Matthew Kuehnert, MD12; Christine K. Olson, MD1; Margaret A. Honein, PhD2; Maria Rivera, MPH1; Denise J. Jamieson, MD1; Sonja A. Rasmussen, MD13 Corresponding author: Emily E. Petersen, 770-488-7100, [email protected]. 1Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; 2Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, CDC; 3Office of the Director, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), CDC; 4Epidemic Intelligence Service, CDC; 5Office of the Director, National Center for Immunization and Respiratory Diseases (NCIRD), CDC; 6Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; 7Influenza Division, NCIRD, CDC; 8Division of Reproductive Endocrinology & Infertility, Department of Gynecology & Obstetrics, Emory University School of Medicine;9Division of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC; 10Division of Vector-Borne Diseases, NCEZID, CDC; 11Division of Preparedness and Emerging Infections, NCEZID, CDC; 12Division of Healthcare Quality Promotion, NCEZID, CDC; 13Division of Public Health Information Dissemination, Center for Surveillance, Epidemiology, and Laboratory Services, CDC.

Update: Interim Guidance for Health Care Providers Caring for Women of Reproductive Age with Possible Zika Virus Exposure — United States, 2016Early Release / March 25, 2016 / 65 http://www.cdc.gov/mmwr/volumes/65/wr/mm6512e2er.htm?s_cid=mm6512e2er_w

ReferencesOster AM, Brooks JT, Stryker JE, et al. Interim guidelines for prevention of sexual transmission of Zika virus—United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:120–1. CrossRefPubMedFoy BD, Kobylinski KC, Foy JLC, et al. Probable non-vector-borne transmission of Zika virus, Colorado, USA. Emerg Infect Dis 2011;17:880–2. CrossRef PubMedHills SL, Russell K, Hennessey M, et al. Transmission of Zika virus through sexual contact with travelers to areas of ongoing transmission—continental United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:215–6. CrossRef PubMedVenturi G, Zammarchi L, Fortuna C, et al. An autochthonous case of Zika due to possible sexual transmission, Florence, Italy, 2014. Euro Surveill 2016;21:30148. CrossRef PubMedMansuy JM, Dutertre M, Mengelle C, et al. Zika virus: high infectious viral load in semen, a new sexually transmitted pathogen? Lancet Infect Dis 2016;S1473-3099(16)00138-9.Musso D, Roche C, Robin E, Nhan T, Teissier A, Cao-Lormeau VM. Potential sexual transmission of Zika virus. Emerg Infect Dis 2015;21:359–61. CrossRef PubMedAtkinson B, Hearn P, Afrough B, et al. Detection of Zika virus in semen[Letter]. Emerg Infect Dis 2016. Published online March 2016. CrossRefPetersen EE, Polen KN, Meaney-Delman D, et al. Update: interim guidance for health care providers caring for women of reproductive age with possible Zika virus exposure—United States, 2016. MMWR Morb Mortal Wkly Rep 2016. Published online March 25, 2016.Duffy MR, Chen TH, Hancock WT, et al. Zika virus outbreak on Yap Island, Federated States of Micronesia. N Engl J Med 2009;360:2536–43. CrossRef PubMedCDC. Contraception. Atlanta, GA: US Department of Health and Human Services, CDC; 2015. http://www.cdc.gov/reproductivehealth/unintendedpregnancy/contraception.htm Top * http://www.cdc.gov/zika/geo/index.html. † http://www.cdc.gov/zika/geo/united-states.html. § Clinical illness consistent with Zika virus disease includes one or more of the following signs or symptoms: acute onset of fever, maculopapular rash, arthralgia, or conjunctivitis. ¶ http://www.cdc.gov/zika/prevention. ** http://www.cdc.gov/zika/hc-providers/diagnostic.html. Top BOX. Recommendations for prevention of sexual transmission of Zika virus for couples in which a man has traveled to or resides in an area with active Zika virus transmissionCouples in which a woman is pregnantCouples in which a woman is pregnant should use condoms consistently and correctly or abstain from sex for the duration of the pregnancy. Other couples concerned about sexual transmission*Couples in which a man had confirmed Zika virus infection or clinical illness consistent with Zika virus disease should consider using condoms or abstaining from sex for at least 6 months after onset of illness. Couples in which a man traveled to an area with active Zika virus transmission but did not develop symptoms of Zika virus disease should consider using condoms or abstaining from sex for at least 8 weeks after departure from the area. Couples in which a man resides in an area with active Zika virus transmission but has not developed symptoms of Zika virus disease might consider using condoms or abstaining from sex while active transmission persists. * Couples who do not desire pregnancy should use the most effective contraceptive methods that can be used correctly and consistently in addition to condoms, which also reduce the risk for sexually transmitted infections. Couples planning conception have a number of factors to consider, which are discussed in more detail in the following: Petersen EE, Polen KN, Meaney-Delman D, et al. Update: interim guidance for health care providers caring for women of reproductive age with possible Zika virus exposure—United States, 2016. MMWR Morb Mortal Wkly Rep 2016. Published online March 25, 2016.

CDC issued interim guidance for the prevention of sexual transmission of Zika virus on February 5, 2016 (1). The following recommendations apply to men who have traveled to or reside in areas with active Zika virus transmission* and their female or male sex partners. These recommendations replace the previously issued recommendations and are updated to include time intervals after travel to areas with active Zika virus transmission or after Zika virus infection for taking precautions to reduce the risk for sexual transmission. This guidance defines potential sexual exposure to Zika virus as any person who has had sex (i.e., vaginal intercourse, anal intercourse, or fellatio) without a condom with a man who has traveled to or resides in an area with active Zika virus transmission. This guidance will be updated as more information becomes available. Zika virus can be sexually transmitted from a man to his sex partners. Zika virus infection is of particular concern during pregnancy. The first documented case of sexual transmission of Zika virus was in 2008 (2); transmission was from a man to a woman, and sexual contact occurred a few days before the man’s symptom onset. The first case of sexual transmission associated with the current outbreak was reported in early February (Dallas County Health and Human Services, unpublished data, 2016). In late February 2016, CDC reported two additional confirmed cases of sexual transmission of Zika virus from men returning from areas with active Zika virus transmission to their sex partners in the United States; these transmissions occurred in early 2016 (3). As of March 18, 2016, CDC has reported three additional cases, for a total of six confirmed cases of sexual transmission in the United States associated with this outbreak.† Another recent report described a case of sexual transmission that occurred in Italy in 2014 (4). In addition, there have been two reports of replication-competent Zika virus isolated from semen at least 2 weeks after onset of illness; blood plasma specimens collected at the same time as the semen specimens tested negative for Zika virus by reverse transcription-–polymerase chain reaction (RT-PCR) (5,6). Semen collected from a third man with Zika virus infection had virus particles detectable by RT-PCR at 62 days after fever onset; RT-PCR of blood at that time was negative (7). Because serial semen specimens were not collected for these three cases, the duration of persistence of infectious Zika virus in semen remains unknown. All reported cases of sexual transmission involved vaginal or anal sex with men during, shortly before onset of, or shortly after resolution of symptomatic illness consistent with Zika virus disease. It is not known whether infected men who never develop symptoms can transmit Zika virus to their sex partners. Sexual transmission of Zika virus from infected women to their sex partners has not been reported. Sexual transmission of many infections, including those caused by other viruses, is reduced by consistent and correct use of latex condoms. Top Recommendations for Men and Their Pregnant PartnersMen who have traveled to or reside in an area with active Zika virus transmission and their pregnant sex partners should consistently and correctly use condoms during sex (i.e., vaginal intercourse, anal intercourse, or fellatio) or abstain from sex for the duration of the pregnancy. This course is the best way to avoid even a minimal risk of sexual transmission of Zika virus, which could have adverse fetal effects when contracted during pregnancy. Pregnant women should discuss their male sex partner’s history of travel to areas with active Zika virus transmission and history of illness consistent with Zika virus disease§ with their health care provider; providers can consult CDC’s guidance for evaluation and testing of pregnant women (8). Top Updated RecommendationsRecommendations for men and their nonpregnant sex partners. Men and their nonpregnant sex partners (couples) who want to reduce the risk for sexual transmission of Zika virus should use condoms consistently and correctly during sex or abstain from sex. Based on expert opinion and limited but evolving information about the sexual transmission of Zika virus, the recommended duration of consistent condom use or abstinence from sex depends on whether men had confirmed infection or clinical illness consistent with Zika virus disease and whether men are residing in an area with active transmission (Box). The rationale for selection of these timeframes is available elsewhere (8). Several factors could influence a couple’s level of concern about sexual transmission of Zika virus. The risk for acquiring mosquito-borne Zika virus in areas with active transmission depends on the duration and extent of exposure to infected mosquitoes and the steps taken to prevent mosquito bites.¶ According to currently available information, most Zika virus infections appear to be asymptomatic, and when illness does occur, it is usually mild with symptoms lasting from several days to a week; severe disease requiring hospitalization is uncommon (9). Transmission of Zika virus is of particular concern during pregnancy. Couples who do not desire pregnancy should use available strategies to prevent unintended pregnancy, including use of the most effective contraceptive methods that can be used correctly and consistently (10). In addition, couples should be advised that correct and consistent use of condoms reduces the risk for sexually transmitted infections. Top Zika Virus Testing and Sexual TransmissionAt present, Zika virus testing for the assessment of risk for sexual transmission is of uncertain value, because current understanding of the duration and pattern of shedding of Zika virus in the male genitourinary tract is limited. Therefore, neither serum nor semen testing of men for the purpose of assessing risk for sexual transmission is currently recommended. Zika virus testing is recommended for persons who have had possible sexual exposure to Zika virus and develop signs or symptoms consistent with Zika virus disease.** A pregnant woman with possible sexual exposure to Zika virus should be tested if either she or her male partner developed symptoms consistent with Zika virus disease (8). CDC urges health care providers to report cases of suspected sexual transmission of Zika virus to local and state health departments. Top AcknowledgmentsWafaa El-Sadr, Columbia University, New York, New York; Daniel R. Kuritzkes, Brigham and Women’s Hospital, Boston, Massachusetts; Amesh Adalja, UPMC Center for Health Security and University of Pittsburgh School of Medicine, Pennsylvania; Jeffrey Duchin, Public Health-Seattle & King County, Washington; Trish Perl, Johns Hopkins School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland.

Alexandra M. Oster, MD1; Kate Russell, MD2; Jo Ellen Stryker, PhD1; Allison Friedman, MS3; Rachel E. Kachur, MPH3; Emily E. Petersen, MD4; Denise J. Jamieson, MD4; Amanda C. Cohn, MD5; John T. Brooks, MD1 Corresponding author: Alexandra M. Oster, [email protected], 404-639-6141. Top 1Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; 2Epidemic Intelligence Service and Influenza Division, National Center for Immunization and Respiratory Diseases, CDC; 3Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; 4Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; 5Office of the Director, National Center for Immunization and Respiratory Disease, CDC.

Update: Interim Guidance for Prevention of Sexual Transmission of Zika Virus — United States, 2016Early Release / March 25, 2016 / 65 http://www.cdc.gov/mmwr/volumes/65/wr/mm6512e3er.htm?s_cid=mm6512e3er_w

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Friday, March 25, 2016 Pregnant Woman Who Traveled to an Affected Country Listed as Third Case of Zika Virus Reported in Kentucky A woman who is pregnant is the third Kentucky resident who has tested positive for Zika virus disease after traveling to an affected area where the virus is circulating, the Kentucky Department for Public Health (DPH) is reporting. Test results were reported to DPH by the Centers for Disease Control and Prevention (CDC), which has been tracking cases across the United States. The patient is from the Louisville area. She experienced Zika-related symptoms after traveling to Central America in recent months and has recovered from the illness. Increasing scientific evidence suggests a link between infection in pregnant women and infants born with birth defects such as microcephaly. Microcephaly is a condition where the head is smaller than normal and may lead to a child experiencing a variety of other health challenges including physical and speech functions, seizure, hyperactivity, coordination problems and other brain/neurological disorders Currently, there is no vaccine to prevent infection and no specific antiviral treatment for Zika infection. Its most common symptoms are fever, rash, joint pain and red eyes, although many infected individuals have no symptoms at all. The virus is primarily spread through the bite of an infected mosquito. “DPH continues to strongly advise anyone – especially pregnant women and children – planning to travel to countries where Zika virus is circulating to take steps to protect themselves,” said Dr. Kraig Humbaugh, senior deputy commissioner for DPH. “This includes being knowledgeable about where the virus is spreading, consulting with a healthcare provider, and, most importantly, following public health’s recommendations to avoid mosquito bites.” The virus is not now known to be circulating in the mosquito population in Kentucky. Zika has been increasing in recognition in Brazil, Mexico and most recently in Puerto Rico, Haiti, and the US Virgin Islands. For these reasons, DPH advises that Kentucky travelers follow the advice of the CDC, which continues to advise travelers to protect themselves and their family members from mosquito bites when traveling to affected countries, such as areas in South and Central America and the Caribbean. More information about Zika can be obtained from the DPH Health Alerts website at:http://healthalerts.ky.gov/Pages/Zika.aspx. For a full list of affected countries and regions visit: http://www.cdc.gov/zika/geo/index.html. Localized areas where Zika virus transmission is ongoing can be difficult to determine and are likely to continue to change over time. Zika is considered by the World Health Organization to be a serious international public health threat. Until more is known, the CDC continues to recommend that pregnant women and women trying to become pregnant take the following precautions: • Pregnant women should consider postponing travel to areas where Zika virus transmission is ongoing. Pregnant women who must travel to one of these areas for business or family emergencies should talk to their doctor or other healthcare professional first and strictly follow steps to avoid mosquito bites during the trip. • Women trying to become pregnant should consult with their healthcare professional before traveling to these areas and strictly follow steps to avoid mosquito bites during the trip. • Based on reports of possible Zika transmission through sexual contact, CDC has suggested that pregnant women avoid sexual contact with men who have recently returned from areas with Zika transmission or consistently and correctly use condoms during sex for the duration of the pregnancy. Men returning from these regions with non-pregnant sex partners should consider abstaining from sexual activity or consistently using condoms during sex. The duration of Zika virus being present in semen after infection is not presently known. Travelers to these areas are specifically advised to wear long-sleeved shirts and long pants, and to use approved insect repellents. CDC has additional information online on how travelers can protect themselves and their family members from mosquito bites:http://www.cdc.gov/zika/prevention/index.html. Kentuckians planning international travel are particularly encouraged to consult the CDC’s Travelers’ Health Website, http://wwwnc.cdc.gov/travel/, for country-specific health information for travelers. A weblink about Zika Travel Information,http://wwwnc.cdc.gov/travel/page/zika-travel-information, is found on that site. International travelers to at-risk countries who develop fever, rash and other acute symptoms within two weeks of return to Kentucky should consult with their medical provider. Additional facts and information specifically related to Zika virus can be found online at: http://www.cdc.gov/zika/index.html.

A woman who is pregnant is the third Kentucky resident who has tested positive for Zika virus disease after traveling to an affected area where the virus is circulating, the Kentucky Department for Public Health (DPH) is reporting. Test results were reported to DPH by the Centers for Disease Control and Prevention (CDC), which has been tracking cases across the United States. The patient is from the Louisville area. She experienced Zika-related symptoms after traveling to Central America in recent months and has recovered from the illness. http://healthalerts.ky.gov/Pages/AlertItem.aspx?alertID=42454

Zika Virus – March 25, 2016 Texas has had 27 confirmed cases of Zika virus disease. Of those, 26 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 – 3 Dallas – 4 Fort Bend – 2 Grayson – 1 Harris – 11 Tarrant – 3 Travis – 2 Wise – 1