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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 March 24, 2016CountryLocally acquiredTravel-relatedCanada033

Zika virus cases in Canada, as of March 24, 2016CountryLocally acquiredTravel-relatedCanada033

AbstractBrazil has experienced an unprecedented epidemic of Zika virus (ZIKV), with ~30,000 cases reported to date. ZIKV was first detected in Brazil in May 2015 and cases of microcephaly potentially associated with ZIKV infection were identified in November 2015. Using next generation sequencing we generated seven Brazilian ZIKV genomes, sampled from four self-limited cases, one blood donor, one fatal adult case, and one newborn with microcephaly and congenital malformations. Phylogenetic and molecular clock analyses show a single introduction of ZIKV into the Americas, estimated to have occurred between May-Dec 2013, more than 12 months prior to the detection of ZIKV in Brazil. The estimated date of origin coincides with an increase in air passengers to Brazil from ZIKV endemic areas, and with reported outbreaks in Pacific Islands. ZIKV genomes from Brazil are phylogenetically interspersed with those from other South American and Caribbean countries. Mapping mutations onto existing structural models revealed the context of viral amino acid changes present in the outbreak lineage; however no shared amino acid changes were found among the three currently available virus genomes from microcephaly cases. Municipality-level incidence data indicate that reports of suspected microcephaly in Brazil best correlate with ZIKV incidence around week 17 of pregnancy, although this does not demonstrate causation. Our genetic description and analysis of ZIKV isolates in Brazil provide a baseline for future studies of the evolution and molecular epidemiology in the Americas of this emerging virus.

Nuno Rodrigues Faria1,2,*, Raimunda do Socorro da Silva Azevedo3,*, Moritz U. G. Kraemer2, Renato Souza4, Mariana Sequetin Cunha4, Sarah C. Hill2, Julien Thézé2, Michael B. Bonsall2, Thomas A. Bowden5, Ilona Rissanen5, Iray Maria Rocco4, Juliana Silva Nogueira4, Adriana Yurika Maeda4, Fernanda Giseli da Silva Vasami4, Fernando Luiz de Lima Macedo4, Akemi Suzuki4, Sueli Guerreiro Rodrigues3, Ana Cecilia Ribeiro Cruz3, Bruno Tardeli Nunes3, Daniele Barbosa de Almeida Medeiros3, Daniela Sueli Guerreiro Rodrigues3, Alice Louize Nunes Queiroz3, Eliana Vieira Pinto da Silva3, Daniele Freitas Henriques3, Elisabeth Salbe Travassos da Rosa3, Consuelo Silva de Oliveira3,Livia Caricio Martins3, Helena Baldez Vasconcelos3, Livia Medeiros Neves Casseb3, Darlene de Brito Simith3, Jane P. Messina2,6, Leandro Abade2, José Lourenço2, Luiz Carlos Junior Alcantara7, Maricélia Maia de Lima8, Marta Giovanetti7, Simon I. Hay9,5, Rodrigo Santos de Oliveira1, Poliana da Silva Lemos1, Layanna Freitas de Oliveira1, Clayton Pereira Silva de Lima1, Sandro Patroca da Silva1, Janaina Mota de Vasconcelos1, Luciano Franco1, Jedson Ferreira Cardoso1, João Lídio da Silva Gonçalves Vianez-Júnior1, Daiana Mir10,Gonzalo Bello10, Edson Delatorre10, Kamran Khan11,12, Marisa Creatore13,Giovanini Evelim Coelho14, Wanderson Kleber de Oliveira14, Robert Tesh15,Oliver G. Pybus2,6,†,‡, Marcio R. T. Nunes1,15,†,‡, Pedro F. C. Vasconcelos3,†,‡1Center for Technological Innovation, Evandro Chagas Institute, Ministry of Health, Ananindeua, PA, 67030-000, Brazil.2Department of Zoology, University of Oxford, South Parks Road, Oxford, OX1 3PS UK.3Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ministry of Health, Ananindeua, Pará State, Brazil.4Instituto Adolfo Lutz, University of São Paulo, Brazil.5Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK.6Metabiota, San Francisco, CA 94104, USA.7Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Bahia, Brazil.8Centre of Post Graduation in Collective Health, Department of Health, Universidade Estadual de Feira de Santana, Feira de Santana, Bahia, Brazil.9Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.10Laboratório de AIDS and Imunologia Molecular, Instituto Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil.11Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada.12Department of Medicine, Division of Infectious Diseases, University of Toronto, Canada.13Dalla Lana School of Public Health, University of Toronto, Canada.14Brazilian Ministry of Health, Brasília, Brazil.15Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA.↵‡Correspondening author. E-mail: [email protected] (O.G.P.);[email protected] (M.R.T.N.); [email protected] (P.F.C.V.)↵* These authors contributed equally to this work. ↵† These authors contributed equally to this work. Science 24 Mar 2016:DOI: 10.1126/science.aaf5036

REPORT Zika virus in the Americas: Early epidemiological and genetic findings http://science.sciencemag.org/content/early/2016/03/23/science.aaf5036

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Summary From 1 January 2007 to 23 March 2016, Zika virus transmission was documented in a total of 61 countries and territories. Four of these countries and territories reported a Zika virus outbreak that is now over. Argentina and New Zealand are the latest countries to report sexual transmission of Zika virus. Thus, five countries have now reported locally acquired infection in the absence of any known mosquito vectors, probably through sexual transmission (Argentina, France, Italy, New Zealand and the United States of America).The geographical distribution of Zika virus has steadily widened since the virus was first detected in the Americas in 2014. Autochthonous Zika virus transmission has been reported in 34 countries and territories of this region.So far an increase in microcephaly and other fetal malformations has been reported in Brazil and French Polynesia. Two additional cases, linked to a stay in Brazil, were detected in the United States of America and Slovenia. Panama recently reported a newborn with microcephaly and occipital encephalocoele (neural tube defect) who died a few hours after birth and tested positive for Zika virus by RT-PCR.In the context of Zika virus circulation, 12 countries or territories have reported an increased incidence of Guillain-Barré syndrome (GBS) and/or laboratory confirmation of a Zika virus infection among GBS cases.The mounting evidence from observational, cohort and case-control studies indicates that Zika virus is highly likely to be a cause of microcephaly, GBS and other neurological disorders. Among the tasks ahead are to further quantify the risk of neurological disorders following Zika virus infection, and to investigate the biological mechanisms that lead to neurological disorders.The global prevention and control strategy launched by the World Health Organization (WHO) as a Strategic Response Framework encompasses surveillance, response activities and research, and this situation report is organized under those headings

Zika situation report24 March 2016Zika virus, Microcephaly and Guillain-Barré syndromehttp://who.int/emergencies/zika-virus/situation-report/24-march-2016/en/

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Mar. 24, 2016 Department of Health Daily Zika UpdateOne New Travel-Related Case in Orange CountyContact: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 is one new travel-related case today in Orange County. Of the cases confirmed in Florida, six 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 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 73 *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 1,152 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 12 affected counties – Alachua, Brevard, Broward, 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 4,122 people for active Zika virus and 1,732 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, 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/2016/03/032416-zika-update.html

County Number of Cases (all travel related) Alachua 4 Brevard 2 Broward 11 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 73

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Laboratory-confirmed Zika virus disease cases reported to ArboNET by state or territory — United States, 2015–2016 (as of March 23, 2016) StatesTravel-associated cases*No. (%)(N=273)Locally acquired cases†No. (%)(N=0)Alabama2 (1)0 (0)Arkansas1 (<1)0 (0)California17 (7)0 (0)Colorado2 (1)0 (0)Connecticut1 (<1)0 (0)Delaware3 (1)0 (0)District of Columbia3 (1)0 (0)Florida70 (26)0 (0)Georgia7 (3)0 (0)Hawaii5 (2)0 (0)Illinois9 (3)0 (0)Indiana4 (1)0 (0)Iowa4 (1)0 (0)Kansas1 (<1)0 (0)Kentucky2 (1)0 (0)Louisiana2 (1)0 (0)Maryland5 (2)0 (0)Massachusetts3 (1)0 (0)Michigan2 (1)0 (0)Minnesota9 (3)0 (0)Missouri1 (<1)0 (0)Montana1 (<1)0 (0)Nebraska2 (1)0 (0)New Hampshire2 (1)0 (0)New Jersey2 (1)0 (0)New York43 (16)0 (0)North Carolina7 (3)0 (0)Ohio8 (3)0 (0)Oklahoma3 (1)0 (0)Oregon6 (2)0 (0)Pennsylvania8 (3)0 (0)Tennessee1 (<1)0 (0)Texas23 (8)0 (0)Virginia7 (3)0 (0)Washington2 (1)0 (0)West Virginia5 (2)0 (0)

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Laboratory-confirmed Zika virus disease cases reported to ArboNET by state or territory — United States, 2015–2016 (as of March 23, 2016) StatesTravel-associated cases*No. (%)(N=273)Locally acquired cases†No. (%)(N=0)Alabama2 (1)0 (0)Arkansas1 (<1)0 (0)California17 (7)0 (0)Colorado2 (1)0 (0)Connecticut1 (<1)0 (0)Delaware3 (1)0 (0)District of Columbia3 (1)0 (0)Florida70 (26)0 (0)Georgia7 (3)0 (0)Hawaii5 (2)0 (0)Illinois9 (3)0 (0)Indiana4 (1)0 (0)Iowa4 (1)0 (0)Kansas1 (<1)0 (0)Kentucky2 (1)0 (0)Louisiana2 (1)0 (0)Maryland5 (2)0 (0)Massachusetts3 (1)0 (0)Michigan2 (1)0 (0)Minnesota9 (3)0 (0)Missouri1 (<1)0 (0)Montana1 (<1)0 (0)Nebraska2 (1)0 (0)New Hampshire2 (1)0 (0)New Jersey2 (1)0 (0)New York43 (16)0 (0)North Carolina7 (3)0 (0)Ohio8 (3)0 (0)Oklahoma3 (1)0 (0)Oregon6 (2)0 (0)Pennsylvania8 (3)0 (0)Tennessee1 (<1)0 (0)Texas23 (8)0 (0)Virginia7 (3)0 (0)Washington2 (1)0 (0)West Virginia5 (2)0 (0)

Zika virus disease in the United States, 2015–2016Language:EnglishEspañolRecommend on FacebookTweetAs of March 23, 2016 (5 am EST) Zika virus disease and Zika virus congenital infection are nationally notifiable conditions.This update from the CDC Arboviral Disease Branch includes provisional data reported to ArboNET for January 1, 2015 – March 23, 2016.US States Travel-associated Zika virus disease cases reported: 273Locally acquired vector-borne cases reported: 0Of the 273 travel-associated infections, 19 are in pregnant women and 6 were sexually transmittedUS Territories Travel-associated cases reported: 4Locally acquired cases reported: 341Of the 341 locally acquired infections, 43 are pregnant women Laboratory-confirmed Zika virus disease cases reported to ArboNET by state or territory — United States, 2015–2016 (as of March 23, 2016) StatesTravel-associated cases* No. (%) (N=273)Locally acquired cases† No. (%) (N=0)Alabama2 (1)0 (0)Arkansas1 (<1)0 (0)California17 (7)0 (0)Colorado2 (1)0 (0)Connecticut1 (<1)0 (0)Delaware3 (1)0 (0)District of Columbia3 (1)0 (0)Florida70 (26)0 (0)Georgia7 (3)0 (0)Hawaii5 (2)0 (0)Illinois9 (3)0 (0)Indiana4 (1)0 (0)Iowa4 (1)0 (0)Kansas1 (<1)0 (0)Kentucky2 (1)0 (0)Louisiana2 (1)0 (0)Maryland5 (2)0 (0)Massachusetts3 (1)0 (0)Michigan2 (1)0 (0)Minnesota9 (3)0 (0)Missouri1 (<1)0 (0)Montana1 (<1)0 (0)Nebraska2 (1)0 (0)New Hampshire2 (1)0 (0)New Jersey2 (1)0 (0)New York43 (16)0 (0)North Carolina7 (3)0 (0)Ohio8 (3)0 (0)Oklahoma3 (1)0 (0)Oregon6 (2)0 (0)Pennsylvania8 (3)0 (0)Tennessee1 (<1)0 (0)Texas23 (8)0 (0)Virginia7 (3)0 (0)Washington2 (1)0 (0)West Virginia5 (2)0 (0) Territories(N=4)(N=341)American Samoa0 (0)14 (4)Puerto Rico3 (75)317 (91)US Virgin Islands1 (25)10 (3)*Travelers returning from affected areas, their sexual contacts, or infants infected in utero †Presumed local mosquito-borne transmission Page last reviewed: February 4, 2016Page last updated: March 23, 2016

Zika Virus UpdateAs of Thursday, March 24, VDH has reported 7 cases of Zika virus disease in Virginia residents to the CDC (2 in Northwest Region, 2 in Northern Region, 1 in Eastern Region, 1 in Central Region and 1 in Southwest Region)

Maryland Confirmed Zika Virus Infections (As of March 23, 2016) Travel-AssociatedLocally Acquired Vector-BorneTotal505

Zika Virus – March 24, 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 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

Zika sixth imported case in Cuba is pregnant arrival of VenezuelaThe infected was in Lara state | Photo: Press Miranda The patient is a Cuban doctor of 32 years who traveled to the island from the state Lara Send by mailPrintRectifyEFEMARCH 24, 2016 - 10:13 A.M. Cuba announced its sixth imported Zika virus case diagnosed in a Cuban medical pregnant came to the island on March 15, from the state of Lara in Venezuela, as revealed in a note from the Ministry of Public Health of the Caribbean country published in the press Local. This is the first pregnant with zika of which the news in Haiti. the patient of 32 years old and resident in the province of Artemisa was admitted "for being pregnant with 19.2 weeks from an area risk of transmission , "although no symptoms of the disease, said the MINSAP. in this case" was conducted epidemiological and vector control established "and took a sample to diagnose the virus, sent to the Institute of Tropical Medicine Pedro Kouri (IPK) in Havana, which confirmed the positive result on Tuesday.So far the patient "continues asymptomatic , " said the note, which reiterates the need to "fulfill all actions for reducing infestation levels mosquitoes of the genus Aedes. " with this, now totaling seven cases of Zika in Cuba, six of them imported and one native, diagnosed in a 21 - year Havana no history of foreign travel. the rest of those affected are a patient of 27 years, four Cubans (this medical, computer engineer, a nurse and a technician) professionals who returned to the island from Venezuela and a natural health of the South American country who traveled to Cuba to study for a graduate . the virus Zika currently circulating in much of Latin and although causes mild symptoms in most infected, the great fear has to do with its likely connection with cases of microcephaly in newborns and neurological syndrome Guillain-Barre syndrome. in recent weeks, Cuba has deployed an action plan to tackle the virus zika, dengue and chikungunya including the mobilization of 9,000 troops of the Armed Forces and 200 police to fight the mosquito that transmits these diseases by spraying in homes and workplaces. http://www.el-nacional.com/mundo/Sexto-importado-Cuba-embarazada-Venezuela_0_817118302.html

S1 Table Clinical symptoms Patient 1 2 3 4 Onset date 01/11/16 01/24/16 01/22/16 01/31/16 Days after symptoms onset * 3 2 5 1 Days after rash onset * <1** 1 1 1 Rash duration 5 days 6 days 2 days 2 days Rash type Macular Macular and maculo-papular Maculo-papular Maculo-papular Low grade fever (duration) - + (2 days) + (4 days) - Headache - - + - Retro-orbital pain - - + - Photophobia - - NI - Fatigue/ malaise - + + - Myalgia - + + - Arthralgia (region) + (wrist and elbows) - + (large and small joints) - Arthritis - - - - Anorexia - - + - Nausea/ vomiting - - + - Diarrhea - - - - Abdominal pain - - - - Dysuria - - - - Bleeding/ petechia - - - - Dizziness/ light headedness - - - - Pruritus + - + + Paresthesias + - - - Conjunctivitis - - - - Edema (local/site) + (hands) - - - Lymphadenopathy (local/ site) - - - - Enanthem NI - NI - Respiratory symptoms - - - - Jaundice - - - - Seizures - - - - * Regarding the date of sample collection; **the collection date was in the first day of rash manifestation S2 Table Clinical symptoms Patient 5 6 7 8 9 Onset date 01/26/16 01/26/16 01/31/16 01/31/16 01/28/16 Days after sypmtons onset * 2 3 1 2 5 Days after rash onset * 2 <1 1 2 2 Rash duration 20 days 4 days 5 days 6 days 3 days Rash type Macular Maculo-papular Maculo-papular Macular and maculo-papular Maculo-papular Low grade fever (duration) - + (1 day) - + (2 days) - Headache + - - + + Retro-orbital pain + - - + + Photophobia + - - - + Fatigue/ malaise + + - + - Myalgia + + - - + Arthralgia (region) - + (wrists, ankles, knees, hands) - + (large and small joints) - Arthritis - - - - - Anorexia + + - - - Nausea/ vomiting + - - - - Diarrhea + - - - - Abdominal pain - + - - - Dysuria - - - - - Bleeding/ petechia - - - - Dizziness/ light headedness + - - - - Pruritus + + + + + Paresthesias + + - - - Conjunctivitis + + - - + Edema + (feet and hands) + (hands) - + - Lymphadenopathy (local/ site) + (Cervical and auricular) - - - + (cervical) Enanthem - - - - - Respiratory symptoms + - - + - Jaundice - - - - - Seizures - - - - - * Regarding the date of sample collection; **the collection date was in the first day of rash manifestation S3 Table Social-demographic data Patient 1 2 3 4 Gender female female male female Age 36 30 24 42 Gestational age (weeks) 18 33 NA 21 Family members illness - - + - Partner illness - - NI - Repellent spray use + + NI + Previous DENV infection + - NI - Domicile in Rio de Janeiro State Duque de Caxias Nova Iguaçu Rio de Janeiro Duque de Caxias NA – not applicable; NI- not informed S4 Table Social demographic data Patient 5 6 7 8 9 Gender female male female female female Age 30 68 20 27 22 Gestational age (weeks) NA NA 17 21 20 Family members illness - + - - - Partner illness - - - - - Repellent spray use + - + + + Previous DENV infection + + - + - Domicile in Rio de Janeiro State Rio de Janeiro Rio de Janeiro Rio de Janeiro Duque de Caxias Rio de Janeiro NA – not applicable; NI- not informed

AbstractZika virus (ZIKV) is an emergent threat provoking a worldwide explosive outbreak. Since January 2015, 41 countries reported autochthonous cases. In Brazil, an increase in Guillain-Barré syndrome and microcephaly cases was linked to ZIKV infections. A recent report describing low experimental transmission efficiency of its main putative vector, Ae. aegypti, in conjunction with apparent sexual transmission notifications prompted the investigation of other potential sources of viral dissemination. Urine and saliva have been previously established as useful tools in ZIKV diagnosis. However, no evidence regarding the infectivity of ZIKV particles present in saliva and urine has been obtained yet. Nine urine and five saliva samples from nine patients from Rio de Janeiro presenting rash and other typical Zika acute phase symptoms were inoculated in Vero cell culture and submitted to specific ZIKV RNA detection and quantification through, respectively, NAT-Zika, RT-PCR and RT-qPCR. Two ZIKV isolates were achieved, one from urine and one from saliva specimens. ZIKV nucleic acid was identified by all methods in four patients. Whenever both urine and saliva samples were available from the same patient, urine viral loads were higher, corroborating the general sense that it is a better source for ZIKV molecular diagnostic. In spite of this, from the two isolated strains, each from one patient, only one derived from urine, suggesting that other factors, like the acidic nature of this fluid, might interfere with virion infectivity. The complete genome of both ZIKV isolates was obtained. Phylogenetic analysis revealed similarity with strains previously isolated during the South America outbreak. The detection of infectious ZIKV particles in urine and saliva of patients during the acute phase may represent a critical factor in the spread of virus. The epidemiological relevance of this finding, regarding the contribution of alternative non vectorial ZIKV transmission routes, needs further investigation.