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Feb. 24, 2016 SURGEON DR. JOHN ARMSTRONG'S DAILY ZIKA UPDATE 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, 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. Of the travel-related cases confirmed in Florida, only three cases are still exhibiting symptoms. According to the CDC, symptoms associated with the Zika virus last between seven to ten 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 three have tested positive for a history of Zika virus infection. The CDC recommends that a pregnant woman with a history of Zika virus and her provider should consider additional ultrasounds. Out of respect of the privacy of these women, no counties or additional information will be shared. 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 4 Hillsborough 3 Lee 3 Miami-Dade 11 Orange 2 Osceola 1 Santa Rosa 1 Seminole 1 St. Johns 1 Cases Involving Pregnant Women* 3 Total 32 *Counties of pregnant women will not be shared. Today, after learning of three pregnant women in Florida who tested positive for Zika virus after traveling from outside the U.S., Governor Rick Scott requested the CDC send 250 additional Zika antibody tests to the state. On Feb. 12, Governor Scott directed State Surgeon General Dr. John Armstrong 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 683 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. State Surgeon General and Secretary of Health Dr. John Armstrong 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 State Surgeon General and Secretary of Health Dr. John Armstrong to issue a Declaration of Public Health Emergency for the counties of residents with travel-associated cases of Zika.The Declaration currently includes the 11 effected counties – Alachua, Brevard, Broward, Hillsborough, Lee, Miami-Dade, Orange, Osceola, 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 4,793 people for active Zika virus and 1,195 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.This week, 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 websitehere.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.

Based on CDC guidance, several pregnant women who have traveled to countries with local-transmission of Zika have received antibody testing and of those three have tested positive for a history of Zika virus infection. The CDC recommends that a pregnant woman with a history of Zika virus and her provider should consider additional ultrasounds. Out of respect of the privacy of these women, no counties or additional information will be shared. 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 4 Hillsborough 3 Lee 3 Miami-Dade 11 Orange 2 Osceola 1 Santa Rosa 1 Seminole 1 St. Johns 1 Cases Involving Pregnant Women* 3 Total 32 *Counties of pregnant women will not be shared. http://www.floridahealth.gov/newsroom/2016/02/022416-zika-update.html

Live stream https://oversight.house.gov/hearing/the-zika-virus-coordination-of-a-multi-agency-response/

WITNESSES AND TESTIMONIESNameTitleOrganizationPanelDocumentDr. Anne SchuchatPrincipal Deputy DirectorCenters for Disease Control and Prevention DocumentDr. Anthony FauciDirector, National Institute of Allergy and Infectious DiseasesNational Institutes of Health DocumentDr. John ArmstrongSurgeon General and Secretary of HealthState of Florida DocumentDr. Bill MoreauManaging Director for Sports MedicineUnited States Olympic Committee Document

BACKGROUND: • The Zika virus is a disease transmitted by Aedes mosquitoes.• The World Health Organization estimates between 3 million to 4 million cases of the Zika virus could appear in the Americas over a 12 month period.• According to the Centers for Disease Control and Prevention, as of February 17, 2016 82 travel-associated Zika cases were reported in the US.• President Obama requested $1.8 billion in emergency funding to prepare for and respond to the spread of Zika.

PURPOSE: • To examine the coordinated federal response to the spread of the Zika virus both within the United States (US) and internationally.• To address confusion and misinformation surrounding measures taken at home and abroad to prevent further transmission of Zika, especially with the 2016 Summer Olympics taking place in Brazil.

THE ZIKA VIRUS: COORDINATION OF A MULTI-AGENCY RESPONSEHEARING DATE: FEBRUARY 24, 2016 2:00 PM 2154 RAYBURN HOBhttps://oversight.house.gov/hearing/the-zika-virus-coordination-of-a-multi-agency-response/

Latest Facts and Advisories as of 2/24/2016Reported cases of Zika in New York City: 8 One of the eight cases was a pregnant woman;All cases contracted Zika while visiting other countries; andAll patients have recovered.http://www1.nyc.gov/site/doh/health/health-topics/zika-virus.page

Map update https://www.google.com/maps/d/edit?hl=en&hl=en&authuser=0&authuser=0&mid=zv94AJqgUct4.kT4qLMXp3SLU

CDC Expert CommentaryAdvising Pregnant Women About Zika: The Latest Guidance From CDCTitilope Oduyebo, MD, MPH Disclosures|February 17, 2016 Print EDITORS' RECOMMENDATIONSZika Virus News & PerspectivesMy AlertsClick the topic below to receive emails when new articles are available. Add "Zika Virus"RELATED DRUGS & DISEASESZika VirusEpidemiology of HypertensionHIV in Pregnancy Hello. I am Dr Titilope Oduyebo, an obstetrician-gynecologist with the Pregnancy and Birth Defects Team for CDC's 2016 Zika Virus Response. Over the next few minutes, I will discuss what we know about Zika virus infection during pregnancy and review the current CDC recommendations for the screening, testing, and management of women with possible Zika virus exposure. Currently, data on pregnant women infected with Zika virus are limited. Data suggest that pregnant women can be infected with Zika virus in any trimester; however, the incidence of Zika virus infection in pregnant women is not known.[1-3] There is no evidence to suggest that pregnant women are more susceptible to Zika virus or experience more severe disease than nonpregnant individuals. With respect to Zika virus transmission, there is evidence of transmission of Zika virus from mother to fetus during pregnancy and also around the time of delivery.[1-3] Because neither a vaccine nor a prophylactic medication is available to prevent Zika virus infection, CDC recommends that pregnant women in any trimester should consider postponing travel to areas with ongoing Zika virus transmission. If a pregnant woman lives in or travels to an area with Zika virus transmission, she should strictly follow steps to avoid mosquito bites. Strategies to avoid mosquito bites are multifaceted. CDC recommends the use of EPA-registered insect repellents, such as DEET, picaridin, and IRIR3535. These insect repellants are considered safe for use in pregnancy when used in accordance with the package label. Other strategies include wearing long-sleeved shirts and pants to cover exposed skin, wearing permethrin-treated clothing, and staying and sleeping in screened-in or air-conditioned rooms. Because the mosquitos that transmit Zika virus bite mostly during the daytime, it is recommended that pregnant women practice these strategies throughout the entire day.[4,5] I would like to briefly review CDC's updated interim guidelines for healthcare providers caring for pregnant women and women of reproductive age with possible Zika virus exposure, which were published on February 5, 2016, in CDC's Morbidity and Mortality Weekly Report.[6] CDC updated its interim guidelines for US healthcare providers caring for pregnant women during a Zika virus outbreak. As in the original guidance, pregnant women with a history of travel to an area with Zika virus infection and who have symptoms consistent with Zika virus disease (which include fever, rash, joint pain, and red eyes) should be prioritized for testing for Zika virus infection. The updated guidelines include a new recommendation to offer serologic testing to pregnant women with a history of travel to an area with ongoing Zika virus transmission and who are asymptomatic (meaning they do not report clinical illness consistent with Zika virus disease). Testing should be performed 2-12 weeks after travel. Although we have limited information about antibody testing of asymptomatic persons, data from related viruses suggest that this testing may be useful when the timeframe of exposure is known. The updated guidelines also provide guidance to healthcare providers caring for women living in areas with ongoing Zika virus transmission and include recommendations for screening, testing, and management of pregnant women and recommendations for counseling women of reproductive age (15-44 years). Pregnant women who reside in areas with ongoing Zika virus transmission have an ongoing risk for infection throughout pregnancy. Thus, in pregnant women with clinical illness consistent with Zika virus disease, testing is recommended during the first week of illness. In addition, testing is recommended at the initiation of prenatal care with follow-up testing at mid–second trimester for asymptomatic pregnant women living in areas with ongoing Zika virus transmission. Local health officials should determine when to implement testing of these pregnant women based on information about levels of Zika virus transmission and laboratory capacity. Healthcare providers should discuss reproductive life plans, including pregnancy intention and timing, with women of reproductive age in the context of the potential risks associated with Zika virus infection. For more detailed information about CDC's recommendations, please read CDC's "Updated Interim Guidelines for Health Care Providers Caring for Pregnant Women and Women of Reproductive Age with Possible Zika Virus Exposure." CDC's guidance will be updated as we learn more. For more information about Zika virus, visit www.cdc.gov/zika. Titilope Oduyebo, MD, MPH , is an obstetrician-gynecologist completing an Epidemic Intelligence Service (EIS) fellowship at the Centers for Disease Control and Prevention. Dr Oduyebo completed internship and residency training at the Brigham and Women's Hospital and Massachusetts General Hospital. She earned her MD from Yale University School of Medicine, MPH from Johns Hopkins School of Public Health, and BS from University of Maryland, College Park. http://www.medscape.com/viewarticle/858892

Zika Virus – Feb. 24, 2016 Texas has 13 cases of Zika virus disease. 12 are travelers who were infected abroad and diagnosed after they returned home. One case involves a Dallas County resident who had sexual contact with someone who acquired the Zika infection while traveling abroad. Case counts by county: Bexar County – 3Dallas County – 2Harris County – 7Travis County - 1

Map update https://www.google.com/maps/d/u/0/edit?mid=zv94AJqgUct4.kI8kcFySb4J0&hl=en

On October 21, 2015, we identified an imported case of ZIKV infection in the central state of Querétaro, Mexico. The patient, a 26-year-old man, had visited Santa Martha, Colombia, during the previous 12 days.

Volume 22, Number 5—May 2016LetterAsian Genotype Zika Virus Detected in Traveler Returning to Mexico from Colombia, October 2015http://wwwnc.cdc.gov/eid/article/22/5/16-0970_article

Washington StateWashington State does not have the type of mosquito (Aedes species) that carries Zika virus. There is currently no risk for local transmission through mosquitoes. However, people who travel to and from areas where Zika is spreading can return with Zika illness. A traveler recently returned to Washington and tested positive for Zika virus (news release, February 22, 2016). People who have returned from Zika-affected areas that are pregnant or having symptoms of Zika illness should contact their healthcare provider.

Registration Date: 02/23/2016 17:02:01 the change in the 02/23/2016 17:02:01MICROCEPHALY Suspect cases reach 4,107 nationwideReport released on Tuesday (23) points also dropped 950 notifications and 583 confirmed for microcephaly and other nervous system disorders The microcephaly suspected cases under investigation by the Ministry of Health and the states reach 4,107 nationwide. The figures are part of the report Epidemiology of microcephaly, released on Tuesday (23). The report also shows that 950 notifications have been discarded and 583 confirmed for microcephaly and other nervous system disorders, suggestive of congenital infection. The 583 confirmed cases occurred in 235 municipalities located in 16 Brazilian states: Alagoas, Bahia, Ceará, Maranhão, Rondônia, Espírito Santo, Goiás, Mato Grosso do Sul, Pará, Paraíba, Pernambuco, Piauí, Rio Grande do Norte, Goiás , Rio de Janeiro and Rio Grande do Sul. Since the 950 cases were discarded because they had normal exams, or submit microcefalias and / or changes in the central nervous system by an infectious causes. It should be noted that the Ministry of Health is investigating all cases of microcephaly and other disorders of the central nervous system, informed by the states and the possible relationship with the Zika virus and other congenital infections. Microcephaly can be caused by various infectious agents beyond Zika, such as syphilis, toxoplasmosis, Other Infectious Agents, Rubella, Cytomegalovirus and Herpes Viral. The 4,107 cases under investigation represent 72.8% of the total cumulative reported 5,640 cases since the beginning of investigations on October 22, 2015 until February 20, 2016. The total reported is spread over 1,101 municipalities in 25 Brazilian states. Amapá and Amazonas are the only states of the federation which has no record of cases. In all, 120 deaths were reported by microcephaly and / or alteration of the central nervous system after birth (stillbirth) or during pregnancy (miscarriage or stillbirth). Of these, 30 were confirmed to microcephaly and / or alteration of the central nervous system. Other research continue 80 and 10 have been discarded. Of the total confirmed, 67 were reported by specific laboratory criteria for Zika virus. However, the Ministry of Health points out that this figure does not represent adequately the total number of cases related to the virus.The folder considers that there was infection Zika mostly mothers who had babies, whose final diagnosis was microcephaly. So far, they are with indigenous circulation of Zika virus 22 units of the federation. They are: Goiás, Minas Gerais, Federal District, Mato Grosso do Sul, Roraima, Amazonas, Pará, Rondônia, Mato Grosso, Tocantins, Maranhão, Piauí, Ceará, Rio Grande do Norte, Paraiba, Pernambuco, Alagoas, Bahia, Espírito Santo , Rio de Janeiro, Sao Paulo and Parana. There was also confirmation of transmission of the virus in 29 countries in the Americas. ORIENTATION - The Ministry of Health advises pregnant women to adopt measures to reduce the presence of Aedes aegypti, with the elimination of breeding sites, and protect themselves from mosquito exposure, such as keeping doors and closed or screened windows, wear pants and shirt sleeve and use repellents allowed for pregnant women. Distribution of reported cases of microcephaly by UF until February 20, 2016 Regions and Federative Units Microcephaly cases and / or malformations suggestive of congenital infection Cumulative total of reported cases from 2015 to 2016 in research confirmed discarded Brazil 4,107 583 950 5,640 Alagoas 102 25 85 212 Bahia 582 120 73 775 Ceará 256 33 46 335 Maranhão 151 14 16 181 Paraíba 440 59 291 790 Pernambuco 1,188 209 204 1,601 Piauí 81 32 14 127 large northern river 275 76 23 374 Sergipe 178 0 10 188 Northeast 3,253 568 762 4,583 Holy Spirit 62 3 8 73 Minas Gerais 27 0 38 65 Rio de Janeiro 250 two 4 256 Sao Paulo 119 0 30 149 Southeast region 458 5 80 543 Acre 26 0 0 26 Amapá No registry No registry No registry Amazon No registry No registry No registry For 10 1 0 11 Rondônia 10 1 0 11 Roraima 11 0 0 11 Tocantins 95 0 17 112 North region 152 two 17 171 Federal district 5 0 19 24 Goiás 80 6 two 88 Mato Grosso 123 0 50 173 Mato Grosso do Sul 5 1 5 11 Midwest region 213 7 76 296 Paraná two 0 13 15 Santa Catarina 0 0 1 1 Rio Grande do Sul 29 1 1 31 South region 31 1 15 47 http://portalsaude.saude.gov.br/index.php/cidadao/principal/agencia-saude/22295-casos-suspeitos-chegam-a-4-107-em-todo-o-pais Agency HealthCare Press Release (61) 3315-2005 / 3580/2351

Latest Facts and Advisories as of 2/11/2016 [En Espanol (PDF)]Reported cases of Zika in New York City: 5 One of the five cases was a pregnant woman;All cases contracted Zika while visiting other countries; andAll patients have recovered.

New York City Zika Tally Page http://www1.nyc.gov/site/doh/health/health-topics/zika-virus.page

Number of confirmed cases of microcephaly in Brazil rises to 5834UOL's in Sao Paulo 02/23/2016 17h36 Listen text 00:00 Print out Report errorNacho Doce / Reuters There are now 583 confirmed cases of babies with microcephaly or changes in the central nervous system in 16 states in the country, according to figures released by the Health Ministry on Tuesday (23). Until last week, were 508 confirmations. There are still 4,107 cases of suspected malformation or nervous system problems that remain to be investigated, spread over 25 states (only Amazon and Amapá not listed).At last report, the number was 3,935. To date, 30 deaths fetus during pregnancy or after birth were confirmed or modified to microcephaly nervous system. There are 80 other deaths under investigation. 67 cases have laboratory confirmation The federal agency says that the confirmed cases, 67 were reported by specific laboratory testing for the virus zika. The ministry, however, stopped to take this issue into account in recent weeks, as it believes that such "data does not represent the total number of cases related to the virus" and that "there was infection zika mostly mothers" who had babies with microcephaly. Besides the zika, microcephaly in babies can be caused by other infectious agents such as syphilis, toxoplasmosis, rubella, cytomegalovirus and herpes virus. Understand the balanceThe control case is being done because several studies have linked the virus to the microcephaly, although not yet known whether alone zika is the cause of microcephaly or if there is another factor that, e.g., facilitates virus entry in the placenta to cause the malformation. Today, all children born with 32 cm or less than head circumference are under investigation and undergo imaging studies and consultations with doctors to confirm or discard neurological problems, which also include eye and hearing. So far the confirmed cases of microcephaly for congenital infection in the country practically equal to 2012 data to 2014, when the notification was not mandatory --and raises the hypothesis that the data are lower than reality. However, experts believe that there was a significant increase in severe cases of microcephaly in the last quarter of 2015. WHO reported an association between the existence of zika and the increased incidence of Guillain-Barré syndrome in French Polynesia, Brazil, El Salvador, Martinique, Colombia, Suriname, Venezuela and Honduras. Already with microcephaly, the relationship was detected in Brazil and French Polynesia. Distribution of reported cases of microcephaly by StateNORTHEAST REGIONAlagoas: 212 (102 in research, 25 confirmed, 85 discarded) Bahia: 775 (582 in research, 120 confirmed, 73 discarded) Ceará: 335 (256 in research, 33 confirmed, 46 discarded) Maranhão: 181 (151 in research, 14 confirmed, 16 discarded) Paraíba: 790 (440 in research, 59 confirmed, 291 discarded) Pernambuco: 1,601 (1,188 in research, 209 confirmed, 204 discarded) Piauí: 127 (81 in research, 32 confirmed, 14 discarded) Rio Grande do Norte: 374 (275 in research, 76 confirmed, 23 discarded) Sergipe: 188 (178 in research, 10 discarded) SOUTHEAST REGIONHoly Ghost: 73 (62 in research, three confirmed, discarded 8) Minas Gerais: 65 (27 in research, 38 discarded) Rio de Janeiro: 256 (250 in research, 2 confirmed, discarded 4) Sao Paulo: 149 (119 in research, 30 discarded) NORTH REGIONAcre 26 (26 research) Amapá: without registration Amazon: without registration Para: 11 (10 in research, 1 confirmed) Rondonia: 11 (10 in 1 research confirmed.) Roraima: 11 (11 research) Tocantins: 112 (95 in research, 17 discarded) MIDWEST REGIONFederal district: 24 (5 under investigation, 19 discarded) Goiás: 88 (80 in research, 6 confirmed two discarded) Mato Grosso: 173 (123 in research, 50 discarded) Mato Grosso do Sul: 11 (5 under investigation, confirmed 1, 5 discarded) SOUTH REGIONParaná: 15 (2 in research, 13 discarded) Santa Catarina: 1 (1 discarded) Rio Grande do Sul: 31 (29 in research, one confirmed, one discarded)