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Key factsMicrocephaly is a condition where a baby is born with a small head or the head stops growing after birth. Microcephaly is a rare condition. One baby in several thousand is born with microcephaly. The most reliable way to assess whether a baby has microcephaly is to measure head circumference 24 hours after birth, compare the value with WHO growth standards, and continue to measure the rate of head growth in early infancy. Babies born with microcephaly may develop convulsions and suffer physical and learning disabilities as they grow older. There are no specific tests to determine if a baby will be born with microcephaly, but ultrasound scans in the third trimester of pregnancy can sometimes identify the problem. There is no specific treatment for microcephaly.

PHEIC page http://www.who.int/entity/emergencies/zika-virus/en/index.html

Microcephalyhttp://www.who.int/emergencies/zika-virus/microcephaly/en/

Incidence of Guillain-Barré syndrome (GBS)  In the context of the Zika virus outbreak, Brazil, Colombia, El Salvador, Suriname and Venezuela have reported an increase of GBS.  In July 2015 the state of Bahia in Brazil reported 42 cases of GBS, 26 of them in patients with a history of symptoms consistent with Zika virus infection. In November 2015 seven patients presenting GBS were laboratory confirmed for Zika virus infection. In 2015, a 19% increase in GBS cases was reported in comparison to the previous year.  To date, none of the reported GBS cases in Colombia have been laboratory confirmed for Zika virus infection or other causes.  Since December 2015 El Salvador recorded 46 GBS cases, including two deaths. None of these cases have been laboratory confirmed for Zika virus infection or other causes.  In Suriname Zika virus infection was confirmed in two of the ten GBS cases reported in 2015.  In January 2016, 252 GBS cases with a spatiotemporal association to Zika virus were reported in Venezuela. Preliminary analysis of the 66 GBS cases in Zulia state indicates a clinical history consistent with Zika virus infection. Zika virus infection was confirmed for three of the GBS cases, including one fatal case.  Martinique has reported two GBS cases where Zika infection has also been confirmed; Puerto Rico has reported one case GBS case. Neither of these occurrences constitute an increase of incidence compared to the previous year.  In French Polynesia, all 42 GBS cases identified during the 2013 – 2014 Zika virus outbreak tested positive for dengue and Zika virus infection.  The cause of the increase in GBS incidence observed in Brazil, Colombia, El Salvador and Suriname remains unknown, especially as dengue, chikungunya and Zika virus have all been circulating simultaneously in the Americas. Investigations to determine the cause of infection are ongoing in countries with increased incidence of GBS. 1 http://governor.hawaii.gov/newsroom/doh-news-release-hawaii-department-of-health-receives-confirmation-of-zika-infection-in-babyborn-with-microcephaly/

Incidence of Microcephaly  On 30 January 2016, the Ministry of Health of Brazil reported 4783 cases of microcephaly and/or central nervous system (CNS) malformation, including 76 deaths since January 2015.  Authorities in Brazil have concluded the investigation into 1113 of the reported cases: 709 cases have been discarded, 404 confirmed and 3670 remain under investigation.  Of the confirmed cases, 387 were compatible with a congenital infection and 17, all from the Northeast Region, had confirmation of Zika virus infection.  Of 76 deaths due to congenital malformations, Zika virus was identified in foetal tissue in five cases, all from the Northeast Region of Brazil. Robust investigations and research are planned to better understand the potential link with Zika virus.  A review of birth data from the 2013 – 2-14 Zika virus outbreak in French Polynesia indicated that the number of congenital abnormalities of the CNS in children born between March 2014 and May 2015 was well above average.  Zika virus infection was confirmed in a baby born with microcephaly in Hawaii1 and in the foetus of a baby in Slovenia after pregnancy termination. No autochthonous transmission of Zika virus has been reported in Hawaii or Slovenia.

Full report http://www.who.int/entity/emergencies/zika-virus/situation-report/who-zika-situation-report-12-02-2016.pdf?ua=1

Zika and potential complicationsRead the full situation report pdf, 628kbSummary WHO has called for a coordinated and multisectoral response through an inter-agency Strategic Response Framework focusing on response, surveillance and research.39 countries have reported locally acquired circulation of the virus since January 2007. Geographical distribution of the virus has steadily expanded.Six countries (Brazil, French Polynesia, El Salvador, Venezuela, Colombia and Suriname) have reported an increase in the incidence of cases of microcephaly and/or Guillain-Barré syndrome (GBS) in conjunction with an outbreak of the Zika virus. Puerto Rico and Martinique have reported cases of GBS associated with Zika virus infection without an increase of incidence. No scientific evidence to date confirms a link between Zika virus and microcephaly or GBS.Women’s reproductive health has been thrust into the limelight with the spread of the Zika virus. The latest evidence suggests that Zika virus infection during pregnancy may be linked to microcephaly in newborn babies.WHO advice on travel to Zika-affected countries includes advice for pregnant women as well as women who are trying to become pregnant and their sexual partners.

Zika situation report12 February 2016http://www.who.int/emergencies/zika-virus/situation-report/12-february-2016/en/

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FOR IMMEDIATE RELEASE February 12, 2016 Contact: ODH Communications (614) 309-7188 Ohio Reports Two New Zika Virus Cases in Returning Travelers COLUMBUS — The Ohio Department of Health (ODH) is reporting the state’s third and fourth cases of Zika virus in returning travelers – a 56-year-old Butler County woman returning from Guyana, and a 60- year-old Licking County man returning from Haiti. The Centers for Disease Control and Prevention (CDC) has reported 52 travel-associated cases of Zika virus in 16 states and the District of Columbia prior to Ohio’s new cases, an increase from 35 cases in 12 states since Tuesday. Zika virus is primarily transmitted through a mosquito bite, and there is no indication that it can spread from person to person through casual contact. CDC has confirmed a U.S. case of Zika virus infection in a non-traveler after the person’s sexual partner returned from an affected country and developed symptoms. Due to the possible association between Zika virus infections in pregnant women and certain birth defects, CDC recommends that pregnant women and women trying to get pregnant consider postponing travel to areas with Zika virus transmission. “Given the number of travelers between Ohio and Zika virus-affected countries, it would not be a surprise to see more cases,” said ODH Medical Director Dr. Mary DiOrio. “There is no vaccine available for Zika virus so it’s important for Ohioans traveling to affected areas to take steps to prevent mosquito bites.” Of people infected with the Zika virus, 80 percent do not have any symptoms. When symptoms occur, they are often mild, lasting from several days to a week, and include fever, rash, joint and muscle pain, conjunctivitis (red eyes), and headache. Severe disease requiring hospitalization is uncommon. Go to the ODH website at http://www.odh.ohio.gov/zika for more information about Zika virus and links to CDC resources including travel advisories for countries where Zika virus transmission is ongoing. ### Note to News Media --- ODH will not issue statewide news releases for future Zika virus cases in Ohio. Local health departments may choose to issue a local news release about new cases in their jurisdictions. ODH will maintain a tally of Ohio’s Zika virus cases on its website at http://www.odh.ohio.gov/zika

The Ohio Department of Health (ODH) is reporting the state’s third and fourth cases of Zika virus in returning travelers – a 56-year-old Butler County woman returning from Guyana, and a 60- year-old Licking County man returning from Haiti. https://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/news/Two New Ohio Zika Cases 2016.pdf

TABLE. Demographic characteristics, clinical course, and signs and symptoms in 30 patients with Zika virus disease identified by the Puerto Rico Department of Health — Puerto Rico, November 23, 2015–January 28, 2016CharacteristicPatientsAge/Illness onset (range)No. (%)Median age (yrs)40 (10–80) Median time from illness onset to specimen collection (days)3 (0–15) History of recent travel* 1 (3)Female 18 (60)Pregnant 1 (3)Hospitalized 3 (10)Signs and symptoms†Rash 23 (77)Myalgia 23 (77)Arthralgia 22 (73)Fever 22 (73)Eye pain 20 (67)Chills 20 (67)Headache 19 (63)Sore throat 12 (40)Petechiae 10 (33)Conjunctivitis 8 (27)Diarrhea 7 (23)Nausea/Vomiting 5 (17)* Travel outside of Puerto Rico and the United States in the 14 days before illness onset. † Signs and symptoms were reported by the patients’ clinician. Top Suggested citation for this article: Thomas DL, Sharp TM, Torres J, et al. Local Transmission of Zika Virus — Puerto Rico, November 23, 2015–January 28, 2016. MMWR Morb Mortal Wkly Rep 2016;65(Early Release):1–6. DOI: http://dx.doi.org/10.15585/mmwr.mm6506e2er.

FIGURE 2. Municipality of residence of persons with Zika virus disease*,† — Puerto Rico, November 23, 2015–January 28, 2016§ *All cases laboratory-confirmed, Dengue Branch, CDC. † Total number of cases = 30; 1 case not shown because location unknown; 1 case in Juncos was travel-associated. § Data current as of February 11, 2016.

FIGURE 1. Zika virus disease cases* (N = 30), by week of onset of patient’s illness — Puerto Rico, November 23, 2015–January 28, 2016*All cases laboratory-confirmed, Dengue Branch, CDC.

ReferencesPan American Health Organization. Epidemiological alert: neurological syndrome, congenital malformations, and Zika virus infection. Implications for public health in the Americas. Washington, DC: World Health Organization, Pan American Health Organization; 2015.http://www.paho.org/hq/index.php?option=com_docman&task=doc_download&Itemid=&gid=32405&lang=en.European Centres for Disease Control and Prevention. Zika virus epidemic in the Americas: potential association with microcephaly and Guillain-Barré syndrome. Stockholm, Sweden: European Centre for Disease Prevention and Control; 2015. http://ecdc.europa.eu/en/publications/Publications/zika-virus-rapid-risk-assessment-8-february-2016.pdf.Noyd DH, Sharp TM. Recent advances in dengue: relevance to Puerto Rico. P R Health Sci J 2015;34:65–70. PubMedPetersen EE, Staples JE, Meaney-Delman D, et al. Interim guidelines for pregnant women during a Zika virus outbreak—United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:30–3. CrossRef PubMedStaples JE, Dziuban EJ, Fischer M, et al. Interim guidelines for the evaluation and testing of infants with possible congenital Zika virus infection—United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:63–7. CrossRef PubMedMusso D, Roche C, Nhan TX, Robin E, Teissier A, Cao-Lormeau VM. Detection of Zika virus in saliva. J Clin Virol 2015;68:53–5. CrossRef PubMedGourinat AC, O’Connor O, Calvez E, Goarant C, Dupont-Rouzeyrol M. Detection of Zika virus in urine. Emerg Infect Dis 2015;21:84–6. CrossRefPubMedFoy BD, Kobylinski KC, Foy JLC, et al. Probable non-vector-borne transmission of Zika virus, Colorado, USA. Emerg Infect Dis 2011;17:880–2. CrossRef PubMedMusso D, Roche C, Robin E, Nhan T, Teissier A, Cao-Lormeau VM. Potential sexual transmission of Zika virus. Emerg Infect Dis 2015;21:359–61. CrossRef PubMedZanluca C, de Melo VC, Mosimann AL, Dos Santos GI, Dos Santos CN, Luz K. First report of autochthonous transmission of Zika virus in Brazil. Mem Inst Oswaldo Cruz 2015;110:569–72. CrossRef PubMedDuffy MR, Chen TH, Hancock WT, et al. Zika virus outbreak on Yap Island, Federated States of Micronesia. N Engl J Med 2009;360:2536–43. CrossRefPubMed Top * http://www.cdc.gov/zika. † http://www.cdc.gov/dengue/resources/denguecasereports/dcif_english.pdf. §http://www.cdc.gov/zika/geo/index.html. ¶ Dengue clinical case management online training course (http://www.cdc.gov/dengue/training/cme.html). ** http://www.salud.gov.pr/Estadisticas-Registros-y-Publicaciones/Pages/Influenza.aspx. †† http://www.salud.gov.pr/Estadisticas-Registros-y-Publicaciones/Pages/Informe-Arboviral.aspx. §§ http://www.cdc.gov/mmwr/volumes/65/wr/mm6505e1er.htm?s_cid=mm6505e1.htm_w. ¶¶ http://www.cdc.gov/Features/stopmosquitoes/index.html.

DiscussionIn May 2015, WHO reported the first local transmission of Zika virus in the Americas in Brazil (10). As of February 3, 2016, local transmission of Zika virus has been reported in 26 countries and territories in the Caribbean and South and Central America.§ The cases described in this report are the first documented local transmission of Zika virus in a jurisdiction of the United States. Aedes aegypti, the most common mosquito vector of Zika virus worldwide, is present throughout Puerto Rico. Therefore, Zika virus is expected to continue to spread throughout the territory, and the 3.5 million residents of Puerto Rico, including approximately 43,000 pregnant women per year, are at risk for Zika virus infection. Approximately 80% of Zika virus infections are asymptomatic (11). The most common symptoms reported by patients in Puerto Rico with laboratory-confirmed Zika virus disease were rash, body and joint pain, and fever. Approximately 25% of patients reported all of the signs and symptoms most commonly associated with Zika virus disease: fever, rash, arthralgia, and conjunctivitis (11). Whether these signs and symptoms are reflective of all persons with symptomatic Zika virus infection, or represent patients with more severe disease, is unknown, as these patients had all sought medical care. This bias might be reflected in the observed rate of patient hospitalization, which was higher than expected on the basis of previous reports (11). Because symptomatic persons with less severe Zika virus disease might not have sought care, the cases reported here might underestimate the incidence of symptomatic Zika virus infection in Puerto Rico. Clinicians in Puerto Rico should report all patients with fever, joint pain, rash, or conjunctivitis to PRDH as a suspected case of Zika virus disease if another etiology has not been identified. All patients with suspected dengue, chikungunya, or Zika virus disease from whom a specimen has been collected during the first 6 days of illness will be tested by PRDH with an assay currently under development at CDC that simultaneously tests for Zika, chikungunya, and dengue virus RNA. Because of possible complications associated with dengue, including increased vascular permeability that might lead to shock and hemorrhage, patients with suspected Zika, dengue, or chikungunya should be managed as dengue patients¶ until another diagnosis is established. Clinicians in Puerto Rico should also be aware of currently ongoing influenza virus transmission at epidemic levels,** and consider influenza in the differential diagnosis when evaluating patients with acute febrile illness. Current case counts of laboratory-confirmed Zika virus disease cases are available online.†† Currently, no medication or vaccine is available to treat or prevent Zika virus disease. To prevent infection, persons residing in affected areas or traveling to areas of active Zika virus transmission should strictly follow steps to avoid mosquito bites. Men who reside in or have traveled to an area of active Zika virus transmission who have a pregnant partner should abstain from sexual activity or consistently and correctly use condoms during sex, and men who reside in or have traveled to an area of active Zika virus transmission who are concerned about sexual transmission of Zika virus might consider abstaining from sexual activity or using condoms consistently and correctly during sex.§§ Mosquito-bite prevention includes using air conditioning or window and door screens when indoors, wearing long sleeves and pants, using permethrin-treated clothing and gear, and using insect repellents. When used according to the product label, EPA-registered insect repellents are safe for pregnant women.¶¶ Residents of Puerto Rico should cover, empty, or discard water containers that might serve as mosquito breeding sites (e.g., tires, plastic containers, and water cisterns). PRDH, CDC, and other partner organizations are urgently implementing broader plans for mosquito control and reduction of risk for Zika virus infection among pregnant women.

Public Health ResponseThe public health response has focused on educating clinicians and the public, establishing laboratory capacity, improving epidemiologic capacity for detecting and monitoring all laboratory-confirmed cases of Zika virus disease in pregnant women, and reducing risk for infection to women who are pregnant. Community cleanup campaigns are being organized throughout the island to remove standing water from containers where Aedes aegyptimosquitos might breed. Additional approaches to effective and sustainable mosquito control are being considered. No cases of microcephaly potentially associated with Zika virus infection have been reported to PRDH. Because microcephaly was not previously captured through routine surveillance, retrospective medical record review of live births during 2013–2015 will be conducted to define the baseline annual incidence of congenital microcephaly among live births, as defined by head circumference below the third percentile for sex and gestational age (5). The Puerto Rico Birth Defects Surveillance and Prevention System (BDSPS) case definition has been modified to capture microcephaly cases not associated with another major birth defect of the central nervous system. Clinicians in Puerto Rico have been advised to report all cases of congenital microcephaly to the BDSPS. PRDH, with assistance from CDC, will maintain a registry of all pregnant women with laboratory-confirmed Zika virus infection, who will be followed throughout their pregnancy. Guillain-Barré syndrome is not a reportable condition in the United States, including Puerto Rico. In conjunction with neurologists in Puerto Rico, a Guillain-Barré syndrome surveillance system is being established to identify cases of clinically diagnosed Guillain-Barré syndrome. . After identification of a case of clinically confirmed Guillain-Barré syndrome, testing for arboviral and other infections will be performed. Cases of Guillain-Barré syndrome will be further investigated to define the association between Zika virus infection and Guillain-Barré syndrome. Because of reports of detection of Zika virus RNA in saliva and urine (6,7), as well as reports of sexual transmission of Zika virus (8,9), patients with laboratory-confirmed Zika virus infection will be followed to determine the persistence of Zika virus RNA, as well as the presence of infectious virus in saliva, urine, and semen.

Selected Additional Patients’ CharacteristicsCase A. On January 13, 2016, a man aged 37 years developed a rash, which resolved over the next 2 days; the next day, he noted paresthesias in his hands and feet, followed by progressive weakness in bulbar and limb muscles and uncontrolled fluctuating hypertension consistent with dysautonomia. On medical evaluation he had bilateral facial weakness, weakness in the upper and lower limbs, and areflexia, and was hospitalized for ascending paralysis. Cerebrospinal fluid protein was elevated, and electrodiagnostic studies showed evidence of a demyelinating polyneuropathy, consistent with the acute inflammatory demyelinating polyneuropathy variant of Guillain-Barré syndrome. The patient responded to treatment with intravenous immunoglobulin. A serum specimen collected 15 days after illness onset, and before administration of intravenous immunoglobulin, was positive for anti-Zika virus IgM antibody, negative for anti-dengue IgM antibody, and negative for Zika, dengue, and chikungunya virus RNA by RT-PCR. A urine specimen collected 19 days after illness onset was also negative for Zika virus RNA by RT-PCR. This is the only patient in Puerto Rico with Guillain-Barré syndrome and confirmed Zika virus disease identified to date. Case B. On January 22, 2016, RT-PCR–confirmed Zika virus disease was diagnosed in a woman in her first trimester of pregnancy; she had sought care because of a 2-day history of nonfebrile eye, body, and joint pain; petechial rash; conjunctivitis; and nausea. Her obstetrician provided counseling regarding risks to her fetus and recommended clinical follow-up, according to CDC interim guidelines (4).

Zika virus, a mosquito-borne flavivirus, spread to the Region of the Americas (Americas) in mid-2015, and appears to be related to congenital microcephaly and Guillain-Barré syndrome (1,2). On February 1, 2016, the World Health Organization (WHO) declared the occurrence of microcephaly cases in association with Zika virus infection to be a Public Health Emergency of International Concern.* On December 31, 2015, Puerto Rico Department of Health (PRDH) reported the first locally acquired (index) case of Zika virus disease in a jurisdiction of the United States in a patient from southeastern Puerto Rico. During November 23, 2015–January 28, 2016, passive and enhanced surveillance for Zika virus disease identified 30 laboratory-confirmed cases. Most (93%) patients resided in eastern Puerto Rico or the San Juan metropolitan area. The most frequently reported signs and symptoms were rash (77%), myalgia (77%), arthralgia (73%), and fever (73%). Three (10%) patients were hospitalized. One case occurred in a patient hospitalized for Guillain-Barré syndrome, and one occurred in a pregnant woman. Because the most common mosquito vector of Zika virus, Aedes aegypti, is present throughout Puerto Rico, Zika virus is expected to continue to spread across the island. The public health response in Puerto Rico is being coordinated by PRDH with assistance from CDC. Clinicians in Puerto Rico should report all cases of microcephaly, Guillain-Barré syndrome, and suspected Zika virus disease to PRDH. Other adverse reproductive outcomes, including fetal demise associated with Zika virus infection, should be reported to PRDH. To avoid infection with Zika virus, residents of and visitors to Puerto Rico, particularly pregnant women, should strictly follow steps to avoid mosquito bites, including wearing pants and long-sleeved shirts, using permethrin-treated clothing and gear, using an Environmental Protection Agency (EPA)-registered insect repellent, and ensuring that windows and doors have intact screens. In November 2015, PRDH, with assistance from CDC, initiated surveillance for Zika virus disease in Puerto Rico by modifying the existing Passive Dengue Surveillance System (3) to include suspected Zika virus disease. Patients in whom a clinician suspected Zika virus disease were reported by sending a serum specimen with a modified dengue case investigation form.† In January 2016, PRDH initiated enhanced surveillance for Zika virus disease by performing Zika virus testing on specimens submitted during November 2015–January 2016 that had tested negative for dengue or chikungunya. Specimens collected within 7 days of illness onset were tested by reverse transcription-polymerase chain reaction (RT-PCR) with updated primers to detect Zika virus RNA. Specimens collected ≥4 days after illness onset were tested by immunoglobulin M (IgM) capture enzyme-linked immunosorbent assay (ELISA) to detect serologic evidence of recent Zika virus infection. Laboratory-confirmed Zika virus disease cases were defined as detection of either Zika virus RNA by RT-PCR, or anti-Zika virus IgM antibody by ELISA with a simultaneous negative anti-dengue virus IgM antibody test. Top Epidemiology and Laboratory InvestigationsDuring November 23, 2015–January 28, 2016, a total of 155 suspected Zika virus disease cases were identified in Puerto Rico, including 82 reported through passive surveillance, and 73 specimens tested through the enhanced surveillance protocol. Overall, 30 (19%) cases had laboratory confirmation of Zika virus disease. Among these cases, one (3%) patient had reported illness onset in November 2015 (the index patient), eight (27%) in December 2015, and 21 (70%) in January 2016. One patient with illness onset in late December reported travel to the Dominican Republic within 14 days of illness onset. After identification of the index case, two cases were detected during the first 2 weeks of December; six cases per week were reported during the 2nd and 3rd weeks of 2016 (Figure 1). Patients resided in municipalities throughout eastern Puerto Rico and the San Juan metropolitan area, and one each resided in Ponce and Guánica (Figure 2). The most frequently reported symptoms were rash, myalgia, arthralgia, and fever (Table). Fever, rash, arthralgia, and conjunctivitis were reported in seven (23%) patients. Coinfection with influenza B virus was reported in one patient. Three (10%) patients were hospitalized: the index patient, one patient with Guillain-Barré syndrome, and another patient who was hospitalized because of thrombocytopenia and clinical suspicion of dengue. Index case. The first case of Zika virus disease identified in Puerto Rico occurred in a man aged 80 years from southeastern Puerto Rico with multiple chronic medical conditions, who reported onset of symptoms on November 23, 2015. Eight days after illness onset, he was evaluated in a hospital emergency department for progressive weakness after several days of watery, nonbloody diarrhea, recent episodes of falling, shoulder pain, chills, malaise, and abdominal pain. He did not report myalgia, headache, or retro-orbital pain. He was febrile, tachycardic, tachypneic, and hypotensive, with bilateral erythematous sclera. Laboratory results revealed leukocytosis with a predominance of neutrophils; hemoconcentration; thrombocytopenia; elevated serum transaminases, blood urea nitrogen, and creatinine; hyponatremia; and hypoglycemia. He received a diagnosis of sepsis, was admitted to the intensive care unit for fluid resuscitation and monitoring, and was treated with broad spectrum antibiotics. Diagnostic considerations included leptospirosis and dengue. He experienced respiratory decompensation requiring intubation and 5 days of mechanical ventilation. He was hospitalized for 2 weeks, during which time he underwent an extensive evaluation. Blood and stool cultures were negative, as were serologic tests for human immunodeficiency virus, Leptospira, and Strongyloides. Schistosoma immunoglobulin G titers were elevated, for which praziquantel was administered. On December 2, serum was collected for dengue and chikungunya diagnostic testing, and was positive for anti-dengue virus IgM, negative for anti-chikungunya virus IgM, and negative for detection of dengue virus and chikungunya virus RNA. Because a hospital-based enhanced surveillance protocol was in place for detection of Zika virus, the same serum specimen was tested for Zika virus infection by RT-PCR with a positive result. Confirmatory molecular diagnostic testing was performed at CDC. Detection of anti-dengue virus IgM antibody likely was a result of cross-reactive anti-Zika virus IgM antibody. Although no pathogen other than Zika virus was identified, the patient’s clinical course suggests that he also had an occult bacterial infection.

SummaryWhat is already known about this topic?Zika virus emerged in the Region of the Americas in mid-2015, and since then, outbreaks have occurred in multiple South American and Caribbean countries and territories. Zika virus infection appears to be related with increased risk for fetal microcephaly and Guillain-Barré syndrome. What is added by this report?The first locally acquired case of Zika virus disease in Puerto Rico was identified in early December 2015. During the subsequent months, 29 additional laboratory-confirmed cases have been detected, including in one pregnant woman and in a man with Guillain-Barré syndrome. What are the implications for public health practice?Clinicians in Puerto Rico and other clinicians evaluating patients with recent travel to Puerto Rico should report all cases of suspected Zika virus disease to public health authorities. Residents of and visitors to Puerto Rico should strictly follow steps to avoid mosquito bites including using air conditioning or window and door screens when indoors, wearing long sleeves and pants, using permethrin-treated clothing and gear, and using insect repellents. When used according to the product label, Environmental Protection Agency-registered insect repellents are safe for pregnant women.

Local Transmission of Zika Virus — Puerto Rico, November 23, 2015–January 28, 2016Early Release / February 12, 2016 / 65(6);1–6 Format:Select onePDF [529 KB]Recommend on FacebookTweetDana L. Thomas, MD1,2; Tyler M. Sharp, PhD3; Jomil Torres, MS1; Paige A. Armstrong, MD4; Jorge Munoz-Jordan, PhD3; Kyle R. Ryff, MPH1; Alma Martinez-Quiñones, MPH5; José Arias-Berríos, MD6; Marrielle Mayshack1,7; Glenn J. Garayalde, MD8; Sonia Saavedra, MD, PhD8; Carlos A. Luciano, MD6; Miguel Valencia-Prado5; Steve Waterman, MD3; Brenda Rivera-García, DVM1 (View author affiliations) Corresponding author: Dana Thomas, [email protected], 787-265-2929. Top 1Office of Epidemiology, Puerto Rico Department of Health; 2Division of State Laboratory Readiness, Office of Public Health Preparedness and Response, CDC; 3Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 4Epidemic Intelligence Service, CDC; 5Puerto Rico Birth Defects Surveillance and Prevention System, Puerto Rico Department of Health; 6Department of Neurology, University of Puerto Rico School of Medicine; 7Office for State, Tribal, Local and Territorial Support, CDC; 8Veterans’ Affairs Caribbean Healthcare System.

Early release MMWR on Local Transmission of Zika Virus — Puerto Rico http://www.cdc.gov/mmwr/volumes/65/wr/mm6506e2er.htm?s_cid=mm6506e2.htm_w

Zika virus diseaseInterim case definition 12 February 2015 These interim case definitions have been developed for the purpose of providing global standardization for classification and reporting of Zika virus cases. WHO guidance for the surveillance of Zika virus disease is currently being developed. WHO will periodically review these interim case definitions and update them as new information becomes available. Suspected caseA person presenting with rash and/or fever and at least one of the following signs or symptoms: arthralgia; orarthritis; orconjunctivitis (non-purulent/hyperaemic). Probable caseA suspected case with presence of IgM antibody against Zika virus1 and an epidemiological link2 Confirmed caseA person with laboratory confirmation of recent Zika virus infection: presence of Zika virus RNA or antigen in serum or other samples (e.g. saliva, tissues, urine, whole blood); orIgM antibody against Zika virus positive and PRNT90 for Zika virus with titre ≥20 and Zika virus PRNT90 titre ratio ≥ 4 compared to other flaviviruses; and exclusion of other flaviviruses Notes1 With no evidence of infection with other flaviviruses 2 Contact with a confirmed case, or a history of residing in or travelling to an area with local transmission of Zika virus within two weeks prior to onset of symptoms.

Zika virus diseaseInterim case definition 12 February 2015 http://who.int/csr/disease/zika/case-definition/en/

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