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WHO issues travel warning for pregnant women as Zika concerns growFRENCH PRESS AGENCY - AFPGENEVAPublished17 hours ago The World Health Organization (WHO) on Tuesday issued stricter precautions for pregnant women in Zika areas, citing growing evidence that the viral disease causes a range of neurological problems in unborn children. "Pregnant women should be advised not [to] travel to areas of ongoing Zika virus outbreaks," the Geneva-based UN health agency said. Pregnant women whose partners live in such regions or travel there should use condoms or abstain from sex until they give birth, it added. WHO had previously advised only that women consult their doctors before taking such trips, and that they protect themselves from mosquito bites if they decide to travel to infection areas. Zika, which normally causes only mild flu symptoms, is mainly transmitted by mosquitoes. There is also a very small number of known cases in which men infected women by having sex. WHO chief Margaret Chan stopped short of recommending that women in the main outbreak areas in Latin American should not get pregnant. But she said that "it makes a lot of sense" to give women information so that they can make choices about pregnancies, and to give them access to contraception. "Zika infections can have very bad outcomes," the WHO director general said. "We can now conclude that the Zika virus is neurotropic," she said, meaning that it attacks the nervous system. In Brazil, which has recorded the highest number of Zika infections, health authorities have reported a rising number of microcephaly cases, a condition in which babies are born with unusually small brains and skulls. While it has been obvious that the Zika outbreak has correlated with a surge in such birth malformations, scientists have been unable to establish a clear link. However, national health agencies and laboratories had provided new information over the past month showing "that there is increasing evidence that there is a causal relationship with Zika virus," a WHO expert panel concluded Tuesday. The virus has now been linked not only to microcephaly, but also to foetal death, foetal growth problems and other neurological problems, Chan said. So far, Zika outbreaks and birth defects have correlated only in Brazil and French Polynesia, but there has been a report of microcephaly cases also from Colombia, Chan acknowledged, adding that WHO was currently trying to get more information from that country. "What we see in Brazil now is what could occur in Colombia and other countries in the next few months, and it is very alarming," said David Heymann, who chairs the emergency expert committee that advises WHO on Zika. Other countries in Latin America had started watching out for birth defects only after the Brazilian cases had become known, and it would take months until mothers who are currently infected with Zika will give birth, he said, explaining the time lag. Heymann's emergency committee urged the scientific community to step up research into the virus. Researchers are meeting at WHO this week in Geneva to identify the most promising vaccine candidates and diagnostic tools for this poorly understood disease. In addition, the emergency committee said development of new mosquito control measures should be stepped up "with particular urgency." The International Atomic Energy Agency (IAEA) on Tuesday decided to transfer technology to Latin America that will allow countries to sterilize mosquitoes by irradiating them, in order to reduce their reproduction rate. "When you control the population of mosquitoes, you are actually controlling the virus," said deputy IAEA chief Aldo Malavasi. http://www.dailysabah.com/health/2016/03/08/who-issues-travel-warning-for-pregnant-women-as-zika-concerns-grow

7:02am March 9, 2016Zika Virus: WHO issues official travel warning to pregnant women advising them not to visit outbreak areas By 9NEWS Pregnant women have been officially advised by the World Health Organisation not to travel to areas affected by the Zika virus outbreak. (AAP) FTBAThe World Health Organization (WHO) has advised pregnant women not to travel to areas affected by the Zika virus outbreak, amid mounting evidence Zika can cause birth defects. "Pregnant women should be advised not travel to areas of ongoing Zika virus outbreaks," the UN agency said in a statement released after an emergency committee meeting on the rapid spread of the mosquito-borne virus. Previous WHO guidelines called for pregnant to be warned of the risk of travel to Zika-hit areas. WHO noted the link between Zika and microcephaly, a severe deformation of the brain among newborns, has not yet been definitively proven. The Zika virus has been connected with microcephaly, a sever deformation of the brain among newborns. (AAP) But WHO chief Margaret Chan told reporters "we do not have to wait until we have definitive proof" before advising pregnant women against travel. "Microcephaly is now only one of several documented birth abnormalities associated with Zika infection during pregnancy," she said. "Grave outcomes include foetal death, placental insufficiency, foetal growth retardation, and injury to the central nervous system." Chan described the latest research on Zika as "alarming", including growing evidence the virus causes the severe neurological disorder Guillain-Barre Syndrome. According to the Australian Department of Foreign Affairs and Trade the Zika virus is active in the following countries: American Samoa Aruba Barbados Bolivia Brazil Colombia Cape Verde Costa Rica Curaçao Dominican Republic Ecuador El Salvador French Guiana Guadelope Guatemala Guyana Haiti Honduras Jamaica Marshall Islands Martinique Mexico Nicaragua Panama Paraguay Puerto Rico Saint Martin Sint Maarten Saint Vincent and the Grenadines Samoa Suriname Thailand Tonga Trinidad and Tobago US Virgin Islands Venezuela Read more at http://www.9news.com.au/health/2016/03/09/07/02/who-advises-pregnant-women-not-to-travel-to-zika-oubreak-areas#1tl6VblqLRkDumcd.99

WHO advises pregnant women to avoid travel to Zika-affected areasTuesday, March 08, 2016 12:28 p.m. CSTBy Stephanie Nebehay and Tom Miles GENEVA (Reuters) - The World Health Organization (WHO) advised pregnant women on Tuesday not to travel to areas with ongoing outbreaks of Zika virus due to the potential risk of birth defects. It said sexual transmission was "relatively common" and that health services in Zika -affected areas should be ready for potential increases in cases of neurological syndromes such as microcephaly and congenital malformations. "Pregnant women whose sexual partners live in or travel to areas with Zika virus outbreaks should ensure safe sexual practices or abstain from sex for the duration of their pregnancy," the WHO said in a statement, based on advice from its Emergency Committee of independent experts. Previously the U.N. health agency had advised women to consider deferring non-essential travel to areas with ongoing transmission of the mosquito-borne virus, which is spreading through Latin America, including Olympics host Brazil. The link between Zika and babies born with small heads and developmental problems, as well as Guillain-Barre syndrome which can cause paralysis, has not been proven scientifically but studies point in that direction, it said. "Clearly Zika infection during pregnancy will produce very bad outcomes," WHO director-general Margaret Chan told a news conference. "It is important we recommend strong public health measures and not wait until we have definitive proof." David Heymann, who chairs the WHO Emergency Committee set up on February 1, said of the recommendation: "The onus is on countries to identify and report where they have outbreaks and where they don't." The WHO did not recommend any general trade or travel restrictions. But it said that existing mechanisms under the WHO's International Health Regulations should be explored, including recommendations that airports be sprayed to eliminate mosquitoes and their breeding grounds. "We can expect more cases and further geographical spread," Chan said. "Sexual transmission is more common than previously assumed." Bruce Aylward, WHO Executive Director for Outbreaks and Emergencies, told reporters that sexual transmission had only been documented as spreading from men to women. "There's no evidence of women-to-men (transmission), so this dead-ends," he said. (Reporting by Stephanie Nebehay and Tom Miles; writing by Stephanie Nebehay; editing by Gareth Jones) http://whbl.com/news/articles/2016/mar/08/who-calls-for-zika-research-says-pregnant-women-should-not-travel-to-affected-areas/

WHO statement on the 2nd meeting of IHR Emergency Committee on Zika virus and observed increase in neurological disorders and neonatal malformationsWHO statement 8 March 2016 The second meeting of the Emergency Committee (EC) convened by the Director-General under the International Health Regulations (2005) (IHR 2005) regarding clusters of microcephaly cases and other neurological disorders in some areas affected by Zika virus was held by teleconference on 8 March 2016, from 13:00 to 16:45 Central European Time. The WHO Secretariat briefed the Committee on action in implementing the Temporary Recommendations issued by the Director-General on 1 February 2016, and on clusters of microcephaly and Guillain-Barré Syndrome (GBS) that have had a temporal association with Zika virus transmission. The Committee was provided with additional data from observational, comparative and experimental studies on the possible causal association between Zika virus infection, microcephaly and GBS. The following States Parties provided information on microcephaly, GBS and other neurological disorders occurring in the presence of Zika virus transmission: Brazil, Cabo Verde, Colombia, France, and the United States of America. The Committee noted the new information from States Parties and academic institutions in terms of case reports, case series, 1 case control study (GBS) and 1 cohort study (microcephaly) on congenital abnormalities and neurologic disease in the presence of Zika virus infection. It reinforced the need for further work to generate additional evidence on this association and to understand any inconsistencies in data from countries. The Committee advised that the clusters of microcephaly cases and other neurological disorders continue to constitute a Public Health Emergency of International Concern (PHEIC), and that there is increasing evidence that there is a causal relationship with Zika virus. The Committee provided the following advice to the Director-General for her consideration to address the PHEIC, in accordance with IHR (2005). Microcephaly, other neurological disorders and Zika virusResearch into the relationship between new clusters of microcephaly, other neurological disorders, including GBS, and Zika virus, should be intensified.Particular attention should be given to generating additional data on the genetic sequences and clinical effect of different Zika virus strains, studying the neuropathology of microcephaly, conducting additional case-control and cohort studies in other and more recently infected settings, and developing animal models for experimental studies.Research on the natural history of Zika virus infection should be expedited, including on the rates of asymptomatic infection, the implications of asymptomatic infection, particularly with respect to pregnancy, and the persistence of virus excretion.Retrospective and prospective studies of the rates of microcephaly and other neurological disorders should be conducted in other areas known to have had Zika virus transmission but where such clusters were not observed.Research should continue to explore the possibility of other causative factors or co-factors for the observed clusters of microcephaly and other neurological disorders.To facilitate this research and ensure the most rapid results:surveillance for microcephaly and GBS should be standardized and enhanced, particularly in areas of known Zika virus transmission and areas at risk,work should begin on the development of a potential case definition for ‘congenital Zika infection’,clinical, virologic and epidemiologic data related to the increased rates of microcephaly and/or GBS, and Zika virus transmission, should be rapidly shared with the World Health Organization to facilitate international understanding of the these events, to guide international support for control efforts, and to prioritize further research and product development.SurveillanceSurveillance for and notification of Zika virus infection should be enhanced with the dissemination of standard case definitions and diagnostics to areas of transmission and at-risk areas; newly infected areas should undertake the vector control measures outlined below.Vector controlVector surveillance, including the determination of mosquito vector species and their sensitivity to insecticides, should be enhanced to strengthen risk assessments and vector control measures.Vector control measures and appropriate personal protective measures should be aggressively promoted and implemented to reduce the risk of exposure to Zika virus.Countries should strengthen vector control measures in the long term and the Director-General of WHO should explore the use of IHR mechanisms, and consider bringing this to a forthcoming World Health Assembly, as means to better engage countries on this issue.Risk communicationsRisk communications should be enhanced in countries with Zika virus transmission to address population concerns, enhance community engagement, improve reporting, and ensure application of vector control and personal protective measures.These measures should be based on an appropriate assessment of public perception, knowledge and information; the impact of risk communication measures should be rigorously evaluated to guide their adaptation and improve their impact.Attention should be given to ensuring women of childbearing age and particularly pregnant women have the necessary information and materials to reduce risk of exposure.Information on the risk of sexual transmission, and measures to reduce that risk, should be available to people living in and returning from areas of reported Zika virus transmission.Clinical carePregnant women who have been exposed to Zika virus should be counselled and followed for birth outcomes based on the best available information and national practice and policies,In areas of known Zika virus transmission, health services should be prepared for potential increases in neurological syndromes and/or congenital malformations.Travel measuresThere should be no general restrictions on travel or trade with countries, areas and/or territories with Zika virus transmission.Pregnant women should be advised not travel to areas of ongoing Zika virus outbreaks; pregnant women whose sexual partners live in or travel to areas with Zika virus outbreaks should ensure safe sexual practices or abstain from sex for the duration of their pregnancy.Travellers to areas with Zika virus outbreaks should be provided with up to date advice on potential risks and appropriate measures to reduce the possibility of exposure to mosquito bites and, upon return, should take appropriate measures, including safe sex, to reduce the risk of onward transmission.The World Health Organization should regularly update its guidance on travel with evolving information on the nature and duration of risks associated with Zika virus infection.Standard WHO recommendations regarding vector control at airports should be implemented in keeping with the IHR (2005). Countries should consider the disinsection of aircraft.Research & product developmentThe development of new diagnostics for Zika virus infection should be prioritized to facilitate surveillance and control measures, and especially the management of pregnancy.Research, development and evaluation of novel vector control measures should be pursued with particular urgency.Research and development efforts should also be intensified for Zika virus vaccines and therapeutics in the medium term.Based on this advice the Director-General declared the continuation of the Public Health Emergency of International Concern (PHEIC). The Director-General endorsed the Committee’s advice and issued them as Temporary Recommendations under IHR (2005). The Director-General thanked the Committee Members and Advisors for their advice. Share PrintMicrocephaly/Zika virus » This page links all WHO information to its response on the Public Health Emergency of International Concern. Related linksWHO Director-General addresses media after Zika Emergency CommitteeMore on the IHR Emergency Committee and MembersWhat is the IHR Emergency Committee and what is a Public Health Emergency of International Concern? pdf, 243kbZika virus disease fact sheetQuestions and answers on Zika virus diseaseFull coverage of the Zika virus disease situationWHO's work on MicrocephalyKey facts: Microcephaly

Pregnant women should be advised not travel to areas of ongoing Zika virus outbreaks; pregnant women whose sexual partners live in or travel to areas with Zika virus outbreaks should ensure safe sexual practices or abstain from sex for the duration of their pregnancy.http://www.who.int/mediacentre/news/statements/2016/2nd-emergency-committee-zika/en/

ReferencesGibbons L, Belizan JM, Lauer JA, Betran AP, Merialdi M, Althabe F. Inequities in the use of cesarean section deliveries in the world. Am J Obstet Gynecol 2012;206:331.e1–19. CrossRefPubMedMusso D, Cao-Lormeau VM, Gubler DJ. Zika virus: following the path of dengue and chikungunya? Lancet 2015;386:243–4. CrossRef PubMedSalvador FS, Fujita DM. Entry routes for Zika virus in Brazil after 2014 world cup: New possibilities. Travel Med Infect Dis 2016;14:49–51. CrossRef PubMedCampos GS, Bandeira AC, Sardi SI. Zika virus outbreak, Bahia, Brazil. Emerg Infect Dis 2015;21:1885–6. CrossRef PubMedZanluca C, Melo VC, Mosimann AL, Santos GI, Santos CN, Luz K. First report of autochthonous transmission of Zika virus in Brazil. Mem Inst Oswaldo Cruz 2015;110:569–72. CrossRefPubMedde Onis M, Garza C, Victora CG, Onyango AW, Frongillo EA, Martines J. The WHO Multicentre Growth Reference Study: planning, study design, and methodology. Food Nutr Bull 2004;25(Suppl):S15–26. CrossRef PubMedSchuler-Faccini L, Ribeiro EM, Feitosa IM, et al. . Possible association between Zika virus infection and microcephaly—Brazil, 2015. MMWR Morb Mortal Wkly Rep 2016;65:59–62. CrossRefPubMedNazer HJ, Cifuentes OL. [Congenital malformations in Latin America in the period 1995–2008][Spanish]. Rev Med Chil 2011;139:72–8. CrossRef PubMedDick GW, Kitchen SF, Haddow AJ. Zika virus. I. Isolations and serological specificity. Trans R Soc Trop Med Hyg 1952;46:509–20. CrossRef PubMedMlakar J, Korva M, Tul N, et al. Zika virus associated with microcephaly. N Engl J Med 2016. Epub ahead of print. CrossRef Top * http://portalsaude.saude.gov.br/index.php/cidadao/principal/agencia-saude/20805-ministerio-da-saudedivulga-boletim-epidemiologico. † http://portalsaude.saude.gov.br/images/pdf/2016/fevereiro/04/2016-004—Dengue-SE3.pdf. § Castilla EE, Orioli IM, Luquetti DV, Dutra MG. Manual de Preenchimento e de Codificação de Anomalias Congênitas no Campo 34 da DN (SINASC). ECLAMC: Estudo Colaborativo Latino Americano de Malformações Congênitas. INaGeMP no IOC; Rio de Janeiro; 2010. ¶ http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sinasc/cnv/nvuf.def. ** http://www2.aids.gov.br/cgi/tabcgi.exe?caumul/anoma.def. †† Microcephaly case excess = (reported no. cases during 2015–2016 - mean no. cases2000–2014) / standard deviation above 2000–2014. §§ http://tabnet.datasus.gov.br. ¶¶ http://www.who.int/nutrition/publications/birthdefects_manual/en/. *** https://agencia.fiocruz.br/fiocruz-identifica-v%C3%ADrus-zika-em-dois-casos-de-microcefalia. ††† http://www.iec.gov.br/index.php/destaque/index/762.

FIGURE 2. Number of reported cases of microcephaly* in full-term† newborns following laboratory-confirmed Zika virus transmission§ — Pernambuco, Paraíba, and Bahia states, Brazil, 2015 * Defined as head circumference ≥3 standard deviations below the mean for age and sex. † The beginning of the first trimester indicator is estimated as 38 weeks preceding the peak period of reported cases of microcephaly. § Confirmed by real time reverse transcription–polymerase chain reaction.

FIGURE 1. Locations of nine states with reported cases of microcephaly in 2015 exceeding 3 standard deviations and three states exceeding 20 standard deviations above the mean number of cases reported annually during 2000–2014 — Brazil, January 1, 2015--January 7, 2016

TABLE. Average annual number of full-term infants reported with microcephaly* during 2000–2014 compared with 2015, prevalence of microcephaly in 2015, and number of states reporting confirmed transmission of Zika virus,† by region — 19 states, Brazil, 2015Region2000–20142015No. statesAverage annual no. casesSDTotal no. casesNo. SDs above meanAverage no. live births§Microcephaly prevalence at birth¶No. states reporting confirmed transmission of Zika virusNorth214.14.711−0.7310,5080.42Northeast943.55.647176.3842,2705.68Southeast365.26.858−1.11,137,4080.52South121.56.23−3.0376,5990.10Center-West413.05.1313.5226,5001.43Total19157.317.757423.62,893,2852.015Abbreviation: SD = standard deviation. * Defined as head circumference ≥3 SDs below the mean for age and sex. † Confirmed by real time reverse transcription–polymerase chain reaction. § From Brazil’s Live Birth Information System, 2009–2013 annual series. ¶ Cases of microcephaly per 10,000 live births.

DiscussionCongenital anomalies, including microcephaly, have a complex and multifactorial etiology and can be caused by infections during pregnancy as well as chromosomal disorders, exposures to environmental toxins, and metabolic diseases.¶¶ The temporal relationship between outbreaks of Zika virus disease and increases in reported prevalence of microcephaly in Brazil, as well as the significant increase in birth prevalence of microcephaly in states with laboratory-confirmed Zika virus transmission, suggest a relationship between these two epidemiologic events. The reported occurrence of the 2015–2016 microcephaly cases, especially in Pernambuco, highlight the temporal relationship between preceding Zika virus transmission and the abrupt increase in birth prevalence of microcephaly. This hypothesis is strengthened by recent virologic evidence. On November 17, 2015, the Flavivirus Laboratory of the Oswaldo Cruz Institute (Rio de Janeiro, Brazil) reported the detection of Zika virus RNA by real time RT-PCR in amniotic fluid samples collected from two pregnant women from Paraíba state whose fetuses were found to have microcephaly and cerebral calcifications by fetal ultrasound, and who reported symptoms compatible with Zika virus disease at 18 and 19 weeks’ gestational age.*** On November 18, 2015, the Evandro Chagas Institute (Pará, Brazil) reported that Zika virus RNA was identified in blood and tissue samples of a neonate with microcephaly who died shortly after birth.††† In addition, on January 12, 2016, MoH reported RT-PCR–confirmed Zika virus infection in two stillborn infants with central nervous system malformations and two neonates with microcephaly who died during the first hours of life, as determined by investigation by the Federal University of Rio Grande do Norte (Natal, Brazil), in collaboration with CDC. The findings in this report are subject to at least four limitations. First, this is an ecologic analysis, with only limited laboratory evidence of Zika virus infection for the pregnancy outcomes described. Second, data were obtained from an ad hoc surveillance system established by MoH after the first cases possibly linked to maternal Zika virus disease were identified. The enhanced awareness regarding this event might have resulted in an increased ascertainment and reporting of cases, including identification of false positives. Third, microcephaly was probably underascertained in Brazil before this event, so the increases might not be as large as suggested by these findings; however, they are substantial increases compared with cases of microcephaly reported during 2000–2014, and in some states, such as Paraíba and Pernambuco, exceed the rate of 5.1 per 10,000 births in Brazil during 1995–2008, estimated by the Latin American Collaborative Study of Congenital Malformations (8). Finally, this study was limited to analysis of the temporal and geospatial association between the increased prevalence of microcephaly in Brazil and earlier Zika virus transmission, and other possible causes of microcephaly were not evaluated in this analysis. The sudden and marked increase in birth prevalence of microcephaly in multiple states in Brazil temporally associated with documented widespread transmission of Zika virus provides additional evidence for the role of Zika virus infection during the first trimester of pregnancy; Zika virus has been demonstrated to cross the placenta, has been associated with congenital infection, and has been recovered in neural tissue (9,10). There is an urgent need for additional research to confirm the link between Zika virus infection and microcephaly through prospective and retrospective analytic studies, as well as to determine the critical Zika virus exposure period during pregnancy with respect to possible fetal infection and microcephaly. Pregnant women should protect themselves from mosquito bites by wearing long sleeves and long pants, applying insect repellent, and when spending time indoors, ensure that rooms are protected by screens or mosquito nets. Top AcknowledgmentsHealth Secretaries of the states of Pernambuco, Paraíba, and Bahia; state Central Laboratories Network National Reference Laboratories; General Coordination of National Dengue Control Program; General Coordination of Surveillance and Response; General Coordination of Public Health Laboratories; CDC; Pan American Health Organization in Washington and the national office in Brazil.

Widespread transmission of Zika virus by Aedes mosquitoes has been recognized in Brazil since late 2014, and in October 2015, an increase in the number of reported cases of microcephaly was reported to the Brazil Ministry of Health.* By January 2016, a total of 3,530 suspected microcephaly cases had been reported, many of which occurred in infants born to women who lived in or had visited areas where Zika virus transmission was occurring. Microcephaly surveillance was enhanced in late 2015 by implementing a more sensitive case definition. Based on the peak number of reported cases of microcephaly, and assuming an average estimated pregnancy duration of 38 weeks in Brazil (1), the first trimester of pregnancy coincided with reports of cases of febrile rash illness compatible with Zika virus disease in pregnant women in Bahia, Paraíba, and Pernambuco states, supporting an association between Zika virus infection during early pregnancy and the occurrence of microcephaly. Pregnant women in areas where Zika virus transmission is occurring should take steps to avoid mosquito bites. Additional studies are needed to further elucidate the relationship between Zika virus infection in pregnancy and microcephaly. Since late 2014, clusters of febrile rash illness have been reported from the Northeast region of Brazil (2,3). These cases were attributed to Zika virus, a flavivirus transmitted by Aedes mosquitoes, when the first cases confirmed by reverse transcription–polymerase chain reaction (RT-PCR) were reported in Bahia and Rio Grande do Norte states in April 2015 (4,5). As of January 2016, transmission had been confirmed in 22 of Brazil’s 26 states and the federal district, and in all five regions of the country.† In Brazil, all recognized congenital anomalies are registered in the Live Birth Information System (Sistema de Informações sobre Nascidos Vivos [SINASC]), which collects information on all live births nationwide and is estimated to have >95% coverage. In SINASC, microcephaly is defined as a head circumference ≥3 standard deviations (SDs) below the mean for age and sex.§ According to the World Health Organization (WHO) Multicenter Growth Reference Study, this corresponds to a head circumference of 30.3 cm for full-term females (gestational age = 259–293 days [approximately 37–42 weeks]) and 30.7 cm for full-term males during the first week of life (6). During 2000–2014, an average of 157.3 (SD = 17.7) cases of microcephaly were registered in SINASC each year.¶ On October 22, 2015, the Secretary of Health of Pernambuco state (in the Northeast region) informed the Brazil Ministry of Health (MoH) of a marked increase in the number of infants born with microcephaly in the state, where 26 cases had been reported since August 2015.** By late October, the Northeast region states of Paraíba and Rio Grande do Norte also were reporting an increase in cases of microcephaly. On October 29, 2015, MoH reported the event to the Pan American Health Organization as a potential Public Health Emergency of International Concern. On November 19, 2015, an ad hoc microcephaly surveillance system was established by MoH for identification of cases of microcephaly both prospectively, and through a retrospective review of hospital records going back to January 1, 2015. Initially, the case definition for the ad hoc system included all full-term infants with a head circumference ≤33 cm. Toward the end of 2015, the MoH defined microcephaly as a head circumference ≤32 cm in any full-term newborn; this case definition is currently used nationwide. The MoH and Secretaries of Health from the affected states led a joint investigation to characterize and identify the etiology of the outbreak, with the support of national research institutes. This report presents temporal and geospatial evidence linking preceding Zika virus transmission with the increased prevalence of microcephaly in Brazil. Among Brazil’s 26 states and the federal capital district, the 19 jurisdictions that reported prospectively and retrospectively identified cases of microcephaly through the ad hoc microcephaly surveillance system during November 19, 2015–January 7, 2016 are included in this analysis. Two analyses were conducted. The first compared the number of cases of microcephaly identified through the ad hoc microcephaly surveillance system during January 1, 2015–January 7, 2016, with the mean number of cases reported to SINASC during 2000–2014 in those 19 jurisdictions, and compared the prevalence of microcephaly in states with documentation of laboratory-confirmed Zika virus transmission with the prevalence in states without confirmed Zika virus transmission. The second analysis examined the timing of peak occurrence of microcephaly cases in the three states with the highest reported prevalence of infants with microcephaly, relative to laboratory confirmation of Zika virus transmission in those states, to estimate the time during pregnancy when exposure to Zika virus might have occurred. Because the SINASC case definition of microcephaly (head circumference ≥3 SDs below the mean for age and sex) was more restrictive than that of the ad hoc microcephaly surveillance system (≤32 cm in any full-term infant), the SINASC criteria were applied to cases reported to the ad hoc system for these analyses. Therefore, only cases reported to the ad hoc surveillance system with a head circumference ≥3 SDs below the mean for age and sex were included. The annual mean number of cases of microcephaly among full-term newborns reported to SINASC during 2000–2014 was calculated and compared with the number of cases of microcephaly that occurred during January 1, 2015–January 7, 2016, and identified through the ad hoc microcephaly surveillance system. The excess number of microcephaly cases was calculated as the number of SDs above the mean number of cases reported during 2000–2014.†† Denominator data for estimation of state-level 2015 microcephaly birth prevalence were obtained by averaging the total number of live births from the SINASC 2009–2013 annual series (the most recent data available).§§ Exact binomial (F-inverse) 95% confidence intervals (CIs) for birth prevalence of microcephaly were calculated for states that did and did not report laboratory-confirmed Zika virus transmission. These two rates were compared with a Pearson’s chi-square test for heterogeneity. To identify potential periods of maternal exposure to Zika virus during pregnancy, assuming an average gestation of 38 weeks (1), weekly counts of cases of microcephaly reported in 2015 in Bahia, Paraíba, and Pernambuco, the three states with the largest increases above the 2000–2014 mean, were reviewed. The beginning of the first trimester of pregnancy was estimated by counting back 38 weeks from the week during which the peak number of cases of microcephaly were reported in each of the three states. The earliest reports of laboratory confirmation of Zika virus transmission in the three states were used as a proxy for the beginning of Zika virus transmission. All statistical significance levels were set at p≤0.05. A total of 574 cases of microcephaly that occurred during January 1, 2015–January 7, 2016, were prospectively and retrospectively identified and registered in the ad hoc microcephaly surveillance system from 19 states. Among these, 58.5% (336) were in females; this excess of female cases has been reported previously (7). The average head circumference of these infants was 29.0 cm (SD = 1.4 cm). During 2000–2014, the mean annual reported number of cases of microcephaly reported to SINASC was 157.3 (SD = 17.7), and by region, ranged from 13.0 in the Center-West to 65.2 in the Southeast (Table). During 2015–2016, 12 states reported microcephaly cases in excess of 3 SDs above the historical 2000–2014 average, including Bahia, Paraíba, and Pernambuco, each of which reported cases in excess of 20 SDs above the historical average (Figure 1). During January 1, 2015–January 7, 2016, Zika virus transmission was laboratory-confirmed by real time quantitative RT-PCR in 15 of the 19 states included in this analysis; among these 15 states, the overall microcephaly birth prevalence was 2.80 (CI = 1.86–4.05) per 10,000 live births, compared with 0.60 (CI = 0.22–1.31) in the four states without laboratory-confirmed Zika virus transmission (p<0.001). The overall microcephaly birth prevalence in the 12 states reporting microcephaly cases >3 SDs above the historical 2000–2014 mean was 4.61 per 10,000 live births (CI = 4.19–5.05). The two states with the highest prevalence rates were Pernambuco (14.62; CI = 12.33–17.17) and Paraíba (10.82; CI = 8.86–13.04). Pernambuco state reported the largest increase in number of reported cases of microcephaly. During epidemiologic weeks 18–39 (corresponding to mid-May–early October) 2015, Pernambuco reported 0–4 cases of microcephaly per week (Figure 2). The number of cases increased substantially during epidemiologic weeks 42–43 (late October), reaching a peak of 27 cases per week during epidemiologic week 46 (mid-November). Assuming an average full-term pregnancy of 38 weeks, the first trimester of pregnancy of mothers of infants with microcephaly born during epidemiologic week 46 occurred during epidemiologic weeks 8–20 (late February–mid May) of 2015. An outbreak of rash illness clinically compatible with Zika virus disease was reported in Pernambuco in December 2014, with laboratory confirmation of Zika virus disease in epidemiologic week 20 of 2015. The estimated first trimester of pregnancy of the mothers of the infants with microcephaly in Pernambuco coincided with occurrence of the rash illness outbreak. Paraíba and Bahia states reported an abrupt increase in the number of infants born with microcephaly in epidemiologic weeks 45 and 47, respectively, and both states reported similar occurrences of a rash illness clinically compatible with Zika virus infection during May 2015 (Figure 2). In Bahia and Paraíba states, cases of microcephaly reported in infants born through epidemiologic week 42 in 2015 (when the first cases in Pernambuco were reported to MoH), were identified retrospectively through the ad hoc microcephaly surveillance system.

SummaryWhat is already known about this topic? An outbreak of Zika virus disease, caused by a flavivirus transmitted by Aedesmosquitoes, occurred in Brazil in early 2015. An increase in the prevalence of infants born with microcephaly has been reported in Brazil since October 2015, in association with clusters of febrile rash illness in pregnant women. What is added by this report? The birth prevalence of microcephaly in Brazil increased sharply during 2015–2016. The largest increase occurred in the Northeast region, where Zika virus transmission was first reported in Brazil. This analysis of 574 cases of microcephaly, detected through a newly established ad hoc microcephaly surveillance system, identified temporal and geospatial evidence linking the occurrence of febrile rash illness consistent with Zika virus disease during the first trimester of pregnancy with the increased birth prevalence of microcephaly. The prevalence of microcephaly in 15 states with laboratory-confirmed Zika virus transmission (2.8 cases per 10,000 live births) significantly exceeded that in four states without confirmed Zika virus transmission (0.6 per 10,000). What are the implications for public health practice? The suggested link between maternal exposure to Zika virus infection during the first trimester of pregnancy and the increased birth prevalence of microcephaly provide additional evidence for congenital infection with Zika virus. Ongoing surveillance is needed to identify additional cases and to fully elucidate the clinical spectrum of illness. Pregnant women should protect themselves from mosquito bites by wearing protective clothing, applying insect repellents, and when indoors, ensuring that rooms are protected with screens or mosquito nets.

Wanderson Kleber de Oliveira, MSc1; Juan Cortez-Escalante, MD2; Wanessa Tenório Gonçalves Holanda De Oliveira, MSc1; Greice Madeleine Ikeda do Carmo, MSc1; Cláudio Maierovitch Pessanha Henriques, MD1; Giovanini Evelim Coelho, PhD1; Giovanny Vinícius Araújo de França, PhD1 (View author affiliations) Corresponding author: Giovanny Vinícius Araújo de França, [email protected]; +55 61 3315-3208. Top 1Ministry of Health, Brasilia, Brazil; 2Pan American Health Organization, Brazil.

Increase in Reported Prevalence of Microcephaly in Infants Born to Women Living in Areas with Confirmed Zika Virus Transmission During the First Trimester of Pregnancy — Brazil, 2015Early Release / March 8, 2016 / 65 http://www.cdc.gov/mmwr/volumes/65/wr/mm6509e2er.htm?s_cid=mm6509e2er_w

1st case of acute myelitis in a patient infected with Zika virus08.03.2016 - PRESS RELEASE Share A first case of acute myelitis following infection with Zika virus has been reported for the first time by a research team from Inserm Unit 1127 Brain and Spinal Cord Institute (Inserm/CNRS/Sorbonne University) and neurologists at Pointe-à-Pitre University Hospital and the University of the Antilles. A young patient in the acute phase of an infection by Zika virus presented motor deficiency in the 4 limbs, associated with very intense pain and acute urinary retention. The presence of the virus was confirmed in the cerebrospinal fluid, blood and urine. This case was the subject of a Case report published in The Lancet on 3 March 2016. (c) Fotolia In January 2016, a 15-year old girl was admitted to the Pointe-à-Pitre University Hospital in Guadeloupe, with left-side hemiplegia. The girl showed urinary retention on her second day in hospital. The left-side hemiplegia and pain became worse and the doctors recorded a loss of sensation in the legs. The researchers detected high concentrations of Zika virus in the serum and cerebrospinal fluid on the second day after admission (9 days after the symptoms began). Tests for shingles, chickenpox, herpes virus, legionellosis and mycoplasma pneumonia were negative. The patient was treated with methylprednisolone (1 g), an anti-inflammatory drug, from the first day and daily for 5 days. Seven days after admission, her neurological condition had improved. At present, the patient is still in hospital but she is out of danger. She has signs of moderate weakness in both legs but is walking unaided again. For the researchers, “this case strengths the hypothesis regarding the neurotropic nature of the Zika virus. It highlights the existence of neurological complications in the acute phase of the infection, while Guillain Barré syndromes are post-infectious complications. Furthermore, this is a single case. Future studies will be needed.” TO CITE THIS PAGE : Press release – Inserm press room – 1st case of acute myelitis in a patient infected with Zika virus Link : http://presse.inserm.fr/en/1st-case-of-acute-myelitis-in-a-patient-infected-with-zika-virus/22840/

ReferencesFauci, AS and Morens, DM. Zika virus in the Americas—yet another arbovirus threat. N Engl J Med.2016; 374: 601–604View in Article | CrossRef | Scopus (1)Larik, A, Chiong, Y, Lee, LC, and Ng, YS. Longitudinally extensive transverse myelitis associated with dengue fever. BMJ Case Rep. 2012;DOI: http://dx.doi.org/10.1136/bcr.12.2011.53783(published online May 11.)View in Article | CrossRefVerma, R, Praharaj, HN, Patil, TB, and Giri, P. Acute transverse myelitis following Japanese encephalitis viral infection: an uncommon complication of a common disease. BMJ Case Reports.2012;DOI: http://dx.doi.org/10.1136/bcr-2012-007094(published online Sept 24.)View in Article | CrossRef | Scopus (3)Ali, M, Safriel, Y, Sohi, J, Llave, A, and Weathers, S. West Nile Virus Infection: MR imaging findings in the nervous system. Am J Neuroradiol. 2005; 26: 289–297View in Article | PubMedSamuel, MA, Wang, H, Siddharthan, V, Morrey, JD, and Diamond, MS. Axonal transport mediates West Nile virus entry into the central nervous system and induces acute flaccid paralysis. Proc Natl Acad Sci USA. 2007; 104: 17140–17145View in Article | CrossRef | PubMed | Scopus (85)

On day 2, she developed dysuria and urinary retention needing catheterisation, but no abnormal urinary frequency or urgency. The left-sided hemiparesis and pain worsened, and we noted loss of temperature sensation below the T2 dermatome on the left and T4 on the right, and bilateral Hoffman signs. Spinal MRI showed lesions of the cervical and thoracic spinal cord. The cervical lesion was enlarged, suggesting oedema (figure). Conus medullaris and lumbar roots were normal, suggesting the bladder dysfunction could be linked to spinal damage. Electromyography and cerebrospinal fluid examination (including isoelectric focusing protein profile) were normal. We detected high concentrations of Zika virus on specific real-time reverse PCR (Eurobio, Les Ulis, France) in serum, urine, and cerebrospinal fluid on the second day of her admission (9 days after symptom onset). PCR for varicella zoster and herpes simplex viruses, Legionella, and Mycoplasma pneumoniae in her cerebrospinal fluid were negative. She had no serological signs of acute infection with cytomegalovirus, Epstein-Barr, chikungunya or dengue viruses, syphilis, or Lyme disease; tests for HIV and human T-cell lymphotropic virus (HTLV) were negative; and aquaporin-A antibodies, a marker of neuromyelitis optica, were absent. FigureMagnetic resonance imaging (MRI) showing myelitis in Zika virus infection (A) T2 sequences showing hypersignal in the thoracic cord T5–T8 (arrow) and enlargement of the cervical spinal cord. (B) Sagittal short time inversion recovery (STIR) sequences showing hypersignal in the cervical spinal cord C4–C7 (arrow). View Large Image | View Hi-Res Image | Download PowerPoint SlideWe started methylprednisolone 1 g daily for 5 days. On the seventh day of admission her neurological condition improved and we could remove the catheter. 1 month after admission she had moderate weakness in both legs but was able to walk unaided. Repeat MRI showed reduced cervical spinal oedema (appendix). The Zika virus epidemic that started in Brazil in May, 2015, spread to 28 countries in February, 2016, including the French Caribbean Islands of Martinique and Guadeloupe. Like dengue, Zika is an arthropod-borne virus of the Flaviviridae family transmitted by Aedes mosquitoes. Until recently, Zika was thought to cause benign infections in humans.1 The presence of Zika virus in the cerebrospinal fluid of our patient with acute myelitis suggests that this virus might be neurotropic. In addition to the usual clinical picture of myelitis she had severe pain. Absence of intrathecal immunoglobulins and normal brain MRI excluded acute disseminated encephalomyelitis. The neurotropism of flaviviruses such as dengue, Japanese encephalitis, and West Nile viruses, which might be responsible for invasive encephalitis and transverse or extensive myelitis,2, 3 is well documented. West Nile virus might also affect lumbosacral nerve roots in addition to the spinal cord,4 and retrograde axonal transport from infected peripheral nerves has been shown.5 Zika virus infection should be considered in patients with acute myelitis living in or travelling from endemic areas, and further study should clarify the spectrum and incidence of neurological associations. Contributors SM, CH, PP, T-HT, ND, GM, ALand, SB, and ALann managed the patient. ALann, SM, and SB wrote the report. Consent to publication was obtained.

In January, 2016, a 15-year-old girl with a history only of an ovarian cyst was admitted to hospital in Pointe-à-Pitre, Guadeloupe, with left hemiparesis. 7 days previously she had presented to the emergency department with left arm pain, frontal headaches, and conjunctival hyperaemia, but no fever, signs of meningeal irritation, or sensory or motor deficits. The day of admission, she developed acute lower back pain, paraesthesia on the left side of her body, and weakness in her left arm. On admission she had slight left-sided weakness and proximal pain of the left arm and leg, exacerbated on movement, but no fever or signs of meningism, and Glasgow Coma Score (GCS) 15.

Acute myelitis due to Zika virus infectionSylvie Mécharles, MD, Cécile Herrmann, MD, Pascale Poullain, MD, Tuan-Huy Tran, MB, Nathalie Deschamps, MB, Grégory Mathon, MD, Anne Landais, MD, Sébastien Breurec, MD, Prof Annie Lannuzel, PhDPublished Online: 03 March 2016DOI: http://dx.doi.org/10.1016/S0140-6736(16)00644-9

Case Report Acute myelitis due to Zika virus infectionhttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00644-9/fulltext

March 8, 2016 SURGEON GENERAL DR. JOHN ARMSTRONG'S DAILY ZIKA UPDATE: NO NEW CASES TODAY http://www.floridahealth.gov/newsroom/2016/03/030816-zika-update.htmlContact: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, State Surgeon General and Secretary of Health Dr. John Armstrong 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 travel-related cases confirmed in Florida, four 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 1 Brevard 1 Broward 7 Hillsborough 3 Lee 3 Miami-Dade 24 Orange 3 Osceola 1 Santa Rosa 1 Seminole 1 St. Johns 1 Cases involving pregnant women* 4 Total 50

Zika virus: WHO emergency committee meets to review precautionsExperts consider whether precautionary measures 'should be strengthened or modified'CBC News Posted: Mar 08, 2016 12:28 PM ET Last Updated: Mar 08, 2016 12:57 PM ET Play Media WHO Emergency Committee on Zika outbreak news conference LIVE 11:59:59 7 shares Facebook Twitter Reddit Google Share Email Related Stories20 Canadians, including pregnant woman, infected by Zika in other countriesThe World Health Organization's emergency committee for the Zika virus met today to consider strengthening its precautionary advise to travellers over the Zika virus. Experts have been reviewing scientific evidence to guide public health recommendations since WHO declared a public health emergency last month, saying the virus's association is "guilty until proven innnocent" for the birth defect microcephaly and Guillain-Barré syndrome, a rare disorder of muscle weakness and sometimes paralysis. Zika virus: What you need to know20 Canadians, including pregnant woman, infected by Zika in other countriesZika virus outbreak an emergency, World Health Organization says The United Nations public health authority will hold a press conference Tuesday on the latest data on the link between the Zika outbreak in Latin America and neurological conditions, travel recommendations, trade and advice for pregnant women. CBC News will carry WHO's news conference live. The committee is considering whether precautionary measures "should be strengthened or modified," WHO said in a release. World Health Organization director general Dr. Margaret Chan declared the Zika virus's associations with microcephaly and other neurological complications a public health emergency in February. (Pierre Albouy/Reuters) Dr. Margaret Chan, WHO's director general, and Dr. David Heymann, chair of the emergency committee, are to give a summary of the meeting and its conclusions. Currently, WHO advises all travellers, including pregnant women, going to areas with locally acquired Zika infections to follow standard precautions to avoid mosquito bites: Use insect repellent.Cover up with clothing.Use screen barriers and bed nets to fend off the day-biting mosquitoes.Eliminate potential mosquito breeding sites. Until more is known about the risk of sexual transmission, WHO also advises all men and women returning from an area where Zika is circulating — especially pregnant women and their partners — to practice safe sex, including through the correct and consistent use of condoms. Canada's chief public health officer, Dr. Gregory Taylor, told a Commons committee on Monday that 20 Canadians, including a pregnant woman, have tested positive for the Zika virus. The infections all occurred while visiting countries with outbreaks. There are no known instances of Canadians being infected while in Canada. Canadian authorities advise women wishing to become pregnant to wait two to three months after their return from an affected area before trying to conceive. The precautionary measure is based on current information on the incubation period and uncertainty about how long the virus remains present in body. http://www.cbc.ca/news/health/zika-who-1.3480937 Similarly, anyone who has travelled to a country with Zika must wait 21 days after returning to Canada before donating blood.