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REFERENCESABSTRACT | INTRODUCTION | METHODS | RESULTS | DISCUSSION | CONCLUSIONS |ARTICLE INFORMATION | REFERENCES 1Dick GW, Kitchen SF, Haddow AJ. Zika virus, I: isolations and serological specificity . Trans R Soc Trop Med Hyg. 1952;46(5):509-520. PubMed | Link to Article2Dick GW. Zika virus, II: pathogenicity and physical properties . Trans R Soc Trop Med Hyg. 1952;46(5):521-534. PubMed | Link to Article3Ioos S, Mallet HP, Leparc Goffart I, Gauthier V, Cardoso T, Herida M. Current Zika virus epidemiology and recent epidemics . Med Mal Infect. 2014;44(7):302-307. PubMed | Link to Article4Foy BD, Kobylinski KC, Chilson Foy JL, et al. Probable non-vector-borne transmission of Zika virus, Colorado, USA . Emerg Infect Dis. 2011;17(5):880-882. PubMed | Link to Article5Tan PC, Rajasingam G, Devi S, Omar SZ. Dengue infection in pregnancy: prevalence, vertical transmission, and pregnancy outcome . Obstet Gynecol. 2008;111(5):1111-1117. PubMed | Link to Article6Pouliot SH, Xiong X, Harville E, et al. Maternal dengue and pregnancy outcomes: a systematic review . Obstet Gynecol Surv. 2010;65(2):107-118. PubMed7Adam I, Jumaa AM, Elbashir HM, Karsany MS. Maternal and perinatal outcomes of dengue in PortSudan, Eastern Sudan . Virol J. 2010;7:153. PubMed | Link to Article8Barthel A, Gourinat AC, Cazorla C, Joubert C, Dupont-Rouzeyrol M, Descloux E. Breast milk as a possible route of vertical transmission of dengue virus? Clin Infect Dis. 2013;57(3):415-417. PubMed | Link to Article9Fritel X, Rollot O, Gerardin P, et al; Chikungunya-Mere-Enfant Team. Chikungunya virus infection during pregnancy, Reunion, France, 2006 . Emerg Infect Dis. 2010;16(3):418-425. PubMed | Link to Article10Gérardin P, Barau G, Michault A, et al. Multidisciplinary prospective study of mother-to-child chikungunya virus infections on the island of La Réunion . PLoS Med. 2008;5(3):e60. PubMed | Link to Article11Stewart RD, Bryant SN, Sheffield JS. West Nile virus infection in pregnancy . Case Rep Infect Dis. 2013;2013:351872. PubMed12Bentlin MR, de Barros Almeida RA, Coelho KI, et al. Perinatal transmission of yellow fever, Brazil, 2009 . Emerg Infect Dis. 2011;17(9):1779-1780. PubMed | Link to Article13Centers for Disease Control and Prevention. Possible West Nile virus transmission to an infant through breast-feeding: Michigan, 2002 . MMWR Morb Mortal Wkly Rep. 2002;51(39):877-878. PubMed14Besnard M, Lastère S, Teissier A, Cao-Lormeau V, Musso D. Evidence of perinatal transmission of Zika virus, French Polynesia, December 2013 and February 2014 . Euro Surveill. 2014;19(13):20751. PubMed | Link to Article15Lanciotti RS, Kosoy OL, Laven JJ, et al. Genetic and serologic properties of Zika virus associated with an epidemic, Yap State, Micronesia, 2007 . Emerg Infect Dis. 2008;14(8):1232-1239. PubMed | Link to Article16Ministério da Saúde, Secretaria de Vigilância em Saúde. Monitoramento dos casos de dengue e febre de chikungunya até a Semana Epidemiológica 30, 2015. Boletim Epidemiológico.2015;46(24):1-8.http://portalsaude.saude.gov.br/images/pdf/2015/setembro/03/2015-029---SE-30.pdf.17Dupont-Rouzeyrol M, O’Connor O, Calvez E, et al. Co-infection with Zika and dengue viruses in 2 patients, New Caledonia, 2014 . Emerg Infect Dis. 2015;21(2):381-382. PubMed | Link to Article18Zanluca 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(4):569-572. PubMed | Link to Article19Campos GS, Bandeira AC, Sardi SI. Zika virus outbreak, Bahia, Brazil . Emerg Infect Dis. 2015;21(10):1885-1886. PubMed | Link to Article20European Centre for Disease Prevention and Control. Zika Virus Epidemic in the Americas: A Potential Association With Microcephaly and Guillain-Barré Syndrome. Stockholm, Sweden: European Centre for Disease Prevention and Control; 2015.21Musso D. Zika virus transmission from French Polynesia to Brazil . Emerg Infect Dis. 2015;21(10):1887. PubMed | Link to Article22Kuno G, Chang GJ. Full-length sequencing and genomic characterization of Bagaza, Kedougou, and Zika viruses . Arch Virol. 2007;152(4):687-696. PubMed | Link to Article23Kutsuna S, Kato Y, Takasaki T, et al. Two cases of Zika fever imported from French Polynesia to Japan, December 2013 to January 2014 [corrected] [published correction appears in Euro Surveill. 2014;19(5):20694] . Euro Surveill. 2014;19(4):20683. PubMed | Link to Article24Hayes EB. Zika virus outside Africa . Emerg Infect Dis. 2009;15(9):1347-1350. PubMed | Link to Article25World Health Organization. Epidemiological alert: neurological syndrome, congenital malformations, and Zika virus infection: implications for public health in the Americas.http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=32405&lang=em. Accessed December 17, 2015.26Ministério da Saúde, Secretaria de Vigilância em Saúde. Protocolo de vigilância e resposta à ocorrência de microcefalia relacionada à infecção pelo vírus Zika.http://portalsaude.saude.gov.br/images/pdf/2015/dezembro/09/Microcefalia---Protocolo-de-vigil--ncia-e-resposta---vers--o-1----09dez2015-8h.pdf. Accessed December 26, 2015.27Centro de Operações de Emergências em Saúde Pública sobre Microcefalias. Monitoramento dos casos de microcefalias no Brasil.http://portalsaude.saude.gov.br/images/pdf/2015/novembro/30/coes-microcefalias---informe-epidemiol--gico---se-47.pdf. Accessed December 26, 2015.28Ministério da Saúde. Microcefalia: 3174 casos são investigados em 20 estados e no Distrito Federal. http://portalsaude.saude.gov.br/index.php/o-ministerio/principal/secretarias/job/webradio/21527-microcefalia-3174-casos-sao-investigados-em-20-estados-e-no-distrito-federal. Accessed January 9, 2016.29Ministério da Saúde. Ministério da Saúde confirma relação entre vírus Zika e microcefalia.http://portalsaude.saude.gov.br/index.php/cidadao/principal/agencia-saude/21014-ministerio-da-saude-confirma-relacao-entre-virus-zika-e-microcefalia. Accessed December 26, 2015.30Ventura CV, Maia M, Bravo-Filho V, Góis AL, Belfort R Jr. Zika virus in Brazil and macular atrophy in a child with microcephaly [published online January 7, 2016] . Lancet. doi:10.1016/S0140-6736(16)00006-4. PubMed31Ministério da Saúde. Nota sobre medida do perímetro cefálico para diagnóstico de bebês com microcefalia relacionada ao vírus Zika. http://www.blog.saude.gov.br/50426-nota-sobre-medida-do-perimetro-cefalico-para-diagnostico-de-bebes-com-microcefalia-relacionada-ao-virus-zika. Accessed December 26, 2015.32World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects . JAMA. 2013;310(20):2191-2194. doi:10.1001/jama.2013.281053. PubMed | Link to Article33Kelly JC. First Zika virus case in continental United States confirmed in Texas. Medscape. January 11, 2016.34Duffy MR, Chen TH, Hancock WT, et al. Zika virus outbreak on Yap Island, Federated States of Micronesia . N Engl J Med. 2009;360(24):2536-2543. PubMed | Link to Article35Alpert SG, Fergerson J, Noël LP. Intrauterine West Nile virus: ocular and systemic findings .Am J Ophthalmol. 2003;136(4):733-735. PubMed | Link to Article

CONCLUSIONSABSTRACT | INTRODUCTION | METHODS | RESULTS | DISCUSSION | CONCLUSIONS |ARTICLE INFORMATION | REFERENCES In summary, 10 of 29 infants with microcephaly (34.5%) had severe ocular abnormalities; these infants were born after a ZIKV outbreak in the state of Bahia in Brazil. The posterior ocular findings were focal pigment mottling and chorioretinal atrophy with a predilection for the macular area, as well as optic disc abnormalities. These findings can contribute to the diagnosis of ZIKV congenital infection in children with congenital microcephaly, although the retinal lesions found in this sample may resemble West Nile virus or toxoplasmosis retinochoroiditis.35 Advances in serologic ZIKV tests and additional studies are necessary to confirm such findings. This study can help guide clinical management and practice, as we observed that a high proportion of the infants with microcephaly had ophthalmologic lesions. Infants with microcephaly should undergo routine ophthalmologic evaluations to identify such lesions. In high-transmission settings, such as South America, Central America, and the Caribbean, ophthalmologists should be aware of the risk of congenital ZIKV-associated ophthalmologic sequelae. ARTICLE INFORMATIONABSTRACT | INTRODUCTION | METHODS | RESULTS | DISCUSSION | CONCLUSIONS |ARTICLE INFORMATION | REFERENCES Corresponding Author: Rubens Belfort Jr, MD, PhD, Vision Institute, Department of Ophthalmology, Paulista Medical School, Federal University of São Paulo, Rua Botucatu, 822, São Paulo 04023-062, Brazil ([email protected]). Submitted for Publication: January 25, 2016; final revision received February 3, 2016; accepted February 3, 2016. Published Online: February 9, 2016. doi:10.1001/jamaophthalmol.2016.0267. Author Contributions: Dr de Paula Freitas had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: de Paula Freitas, de Oliveira Dias, Prazeres, Maia, Belfort. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: de Paula Freitas, de Oliveira Dias, Prazeres, Sacramento, Ko, Maia. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: de Paula Freitas. Obtained funding: Belfort. Administrative, technical, or material support: de Paula Freitas, Prazeres, Sacramento, Maia, Belfort. Study supervision: de Paula Freitas, de Oliveira Dias, Sacramento, Maia, Belfort. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Funding/Support:Hospital Geral Roberto Santos provided the site and materials for ophthalmologic examination. Federal University of São Paulo (Paulista Medical School), Vision Institute (IPEPO), and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) provided funds for travel expenses as well as the materials necessary for the ocular examinations. Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

DISCUSSIONABSTRACT | INTRODUCTION | METHODS | RESULTS | DISCUSSION | CONCLUSIONS |ARTICLE INFORMATION | REFERENCES Findings from this case series demonstrate that 10 of 29 infants (34.5%) born with presumed ZIKV-associated microcephaly have vision-threatening lesions. In 2015, Salvador, Bahia, and several other cities in northeastern Brazil had an unprecedented ZIKV outbreak. This virus became a major public health problem in a short period owing to its association with severe neurologic malformations such as microcephaly and possibly related ocular diseases in newborn infants.14,28 Because the rate of ocular abnormalities is very high in this age group and the retinal lesions differ from other congenital infections described previously in the literature, we hypothesized that a cause and effect relationship between ZIKV infection and ocular abnormalities was possible. The ocular lesions consisted of focal pigment mottling and chorioretinal atrophy with a predilection for the posterior pole, especially the macular area, as well as optic disc abnormalities. No signs of active uveitis or vasculitis were observed. The current data suggest the possibility that even oligosymptomatic or asymptomatic pregnant patients presumably infected with ZIKV may have microcephalic newborns with ophthalmoscopic lesions. An important question is whether patients without microcephaly will need to be screened to identify these ocular lesions. Our study has limitations including generalizability of our findings (because it was conducted at 1 hospital), a small sample, and a lack of prior research studies on the topic. The convenience sample and lack of statistical analysis do not allow us to affirm whether percentages or findings are unique to these data or could be generalizable to presumed ZIKV infection. The growing number of cases, rapid disease dissemination, and epidemic pattern observed in Brazil may indicate the risk of a new pandemic disease throughout the Americas, especially given that the biological vector A aegypti is endemic in Latin America, the Caribbean, and some regions in the United States, where cases have already been reported.25,26,33 These regions where the virus is spreading can likely experience an outbreak with the same types of birth defects including the ophthalmologic lesions observed in this study. Unlike the findings by Duffy et al34 reported in 2009, the current study did not identify conjunctivitis as a frequent finding in ZIKV infection. No mothers reported conjunctivitis during pregnancy when specifically asked about it. Our findings suggest that conjunctivitis may not be an important clinical finding in the differential diagnosis of ZIKV.

RESULTSABSTRACT | INTRODUCTION | METHODS | RESULTS | DISCUSSION | CONCLUSIONS |ARTICLE INFORMATION | REFERENCES Thirty-one infants aged 1 to 6 months had a confirmed diagnosis of microcephaly. Two patients were excluded from the study owing to impossibility of evaluating the results of their serology tests for other infections, as they did not return for blood collection. Of the 29 children, 18 (62.1%) were female. Twenty-three of the 29 mothers (79.3%) had ZIKV signs and symptoms during pregnancy, which included cutaneous rash (21 of 29 mothers [72.4%]), fever (13 mothers [44.8%]), arthralgia (11 mothers [37.9%]), headache (5 mothers [17.2%]), and itch (4 mothers [13.8%]). All mothers denied signs or symptoms of conjunctivitis. Among 23 mothers who reported symptoms during pregnancy, 18 (78.3%) reported ZIKV symptoms during the first trimester of pregnancy, 4 (17.4%) during second trimester, and 1 (4.3%) during the third trimester. No mothers had signs of active or previous uveitis and all had normal findings on ocular examination. Ocular abnormalities were observed in 10 of the 29 patients with microcephaly (34.5%) who were examined. Seventeen of 20 eyes (85.0%) in 10 children had ophthalmoscopic abnormalities. Bilateral findings were found in 7 of 10 patients (70.0%) presenting with ocular lesions, the most common of which were focal pigment mottling and chorioretinal atrophy in 11 of the 17 eyes with abnormalities (64.7%) (Figure 1, Figure 2, Figure 3, and Figure 4). Severe chorioretinal atrophy also was observed and involved the macula in 3 eyes (Figure 1B and Figure 3A), the nasal retina in 3 eyes (Figure 5), and the paramacular area in 5 eyes (Figure 2and Figure 3B). Two distinct components were observed: (1) circumscribed areas of chorioretinal atrophy, which in some areas had no choroidal vessels visible at all (Figure 1B, Figure 2, Figure 3B, Figure 4, andFigure 5); and (2) circumscribed areas of pigmentary clumping (Figure 2, Figure 3B, and Figure 4). Some patients had chorioretinal atrophy surrounded by a hyperpigmented halo and also showed the hyperpigmented mottling (Figure 2, Figure 3B, and Figure 4). Figure 1.Fundus Photographs of a 2-Month-Old GirlThe right eye has granular, pigmentary mottling in the macula (A), and the left eye has a chorioretinal lobulated atrophic lesion and slight pigmentary mottling (B). View Large | Save Figure | Download Slide (.ppt)Figure 2.Fundus Photographs of a 1-Month-Old BoyThe right (A) and left (B) eyes have paramacular superotemporal round chorioretinal atrophy surrounded by a hyperpigmented halo and hyperpigmented mottling. View Large | Save Figure | Download Slide (.ppt)Figure 3.Fundus Photographs of a 1-Month-Old InfantThe right eye has an enlarged cup-disc ratio and macular pigmentary mottling (A), and the left eye has a roundish macular chorioretinal atrophic lesion with a hyperpigmented halo and pigmentary mottling, as well as an enlarged cup-disc ratio of the optic nerve. View Large | Save Figure | Download Slide (.ppt)Figure 4.Fundus Photographs of a 1-Month-Old InfantThe right eye has a superotemporal perimacular chorioretinal scar with perilesional pigmentary mottling (A), and the left eye has similar findings (B). View Large | Save Figure | Download Slide (.ppt)Figure 5.Fundus Photographs of a 20-Day-Old InfantThe right eye has optic disc hypoplasia, peripapillary nasal atrophy, and an excavated nasal round lesion with a hyperpigmented halo, with a colobomatous-like aspect (A), and the left eye has optic disc hypoplasia, peripapillary nasal atrophy, and a retinal nasal lesion with a similar pattern (B). View Large | Save Figure | Download Slide (.ppt)Other ocular findings included optic nerve abnormalities in 8 eyes (47.1%; 2 cases of hypoplasia and 6 cases of severe optic disc cupping), lens subluxation in 1 eye (5.9%), and bilateral iris coloboma (2 eyes [11.8%]) in the same patient with lens subluxation. Data are summarized in the Table. No infants had vasculitis or active uveitis. Table. Ocular Findings in Infants With Microcephaly and Presumed Zika Virus Congenital InfectionView Large | Save Table | Download Slide (.ppt)

METHODSABSTRACT | INTRODUCTION | METHODS | RESULTS | DISCUSSION | CONCLUSIONS |ARTICLE INFORMATION | REFERENCES Study SiteThis study was conducted between December 1 and December 21, 2015. All children and their mothers were evaluated at the Roberto Santos General Hospital, Salvador, Brazil, a tertiary care hospital. Ophthalmologists who are experts in medical/surgical retina, uveitis, and neuro-ophthalmology evaluated the patients. Thirty-one infants with microcephaly due to a possible ZIKV congenital infection and their mothers were referred for ophthalmologic evaluation from other hospitals and health unities. In December 2015, the Brazilian Ministry of Health revised the definition for microcephaly in newborn term infants. The head circumference criterion was reduced from a threshold of 33 cm or less to 32 cm or less,31which was the criterion used in this study. A direct parent (mother or father) provided written informed consent. The Ethics Committee of the Federal University of São Paulo previously approved the study protocol, which followed the tenets of the Declaration of Helsinki.32 A detailed clinical history was obtained, including the prenatal and postnatal history and maternal systemic history. PatientsInclusion Criteria of the Mothers and InfantsInfants with a cephalic circumference of 32 cm or less at birth were included. Other congenital infections included in the differential diagnosis were toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus, syphilis, and human immunodeficiency virus (HIV), which were ruled out through serologic examinations. In all cases, the specific tests performed were part of the routine screening and also included serology in the mothers. All of the cases had negative serology results for syphilis and HIV. None presented with high titers of IgG antibodies or the presence of IgM antibodies specific to toxoplasmosis, cytomegalovirus, herpes simplex virus, or rubella. The suspected diagnosis of congenital ZIKV was also based on clinical features of the mothers during pregnancy, including cutaneous rash, fever, arthralgia, headache, itch, and malaise. Exclusion Criteria of the InfantsNewborn infants were excluded if they had a cephalic diameter that exceeded 33 cm, evidence for another congenital infection such as toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus, or HIV, or a familial history of microcephaly, or if the mother had a history of alcohol or illicit drug use during pregnancy. Ocular ExaminationAll mothers underwent an external ocular examination, biomicroscopy, and dilated indirect ophthalmoscopy. All infants underwent an ocular external examination and indirect ophthalmoscopy. Optic nerve, retinal, and choroidal abnormalities were documented with a wide-field digital imaging system (RetCam Shuttle; Clarity Medical Systems) after pupillary dilation. Owing to the small number of patients included in this case series, a descriptive report was conducted and no statistical analysis was performed.

INTRODUCTIONABSTRACT | INTRODUCTION | METHODS | RESULTS | DISCUSSION | CONCLUSIONS |ARTICLE INFORMATION | REFERENCES The Zika virus (ZIKV) is an arbovirus that carries the name of a forest near Kampala, Uganda. The virus was first identified in rhesus monkeys in 1947 through a sylvatic yellow fever surveillance network in Uganda1 and was further isolated in humans in Uganda and Tanzania in 1952.2 The transmission is mostly vectorial by mosquitoes from the Culicidae family and the Aedes genus, especially Aedes aegypti (urban transmission). The virus usually is transmitted to hematophagous arthropods during their blood meal and reproduces in the host vector without affecting it, remaining in the insect during its entire life span. The virus is transmitted to reservoir animals during the next blood meal.3 Direct interhuman transmission, most likely by sexual intercourse, also has been described,4 and perinatal transmission of arbovirus has been reported for dengue virus (DENV),5- 8 chikungunya virus,9,10 West Nile virus (WNV),11 and yellow fever virus.12 Both DENV8 and West Nile virus reportedly have been transmitted in breast milk.13 There is also some evidence of perinatal and breast milk transmission of ZIKV.14,15 Few human cases were reported until 2007, when a ZIKV outbreak occurred in Yap, Micronesia, even though ZIKV activity had been reported in Africa and Asia through virologic surveillance and entomologic studies.15 At the beginning of 2015, several cases of DENV and chikungunya virus infections were reported in Brazil.16 The number of cases of ZIKV reported in Brazil is uncertain because of problems in detection without the commercial availability of a serologic test. In addition, the signs and symptoms in patients infected with the 3 distinct viruses, ie, DENV, chikungunya virus, and ZIKV, are similar. Moreover, it was estimated that 80% of patients with ZIKV infection are asymptomatic or oligosymptomatic. Finally, ZIKV infection occurs in demographic areas in which A aegypti is endemic and where the mosquito is the biological vector of the 3 distinct viral diseases, and coinfection with these viruses is not uncommon.17 Transmission to the Americas appears to have originated in the Pacific Islands.18 The Brazilian state of Bahia was the first to identify cases in Brazil, although the state of Pernambuco has a larger number of notifications.19 By December 10, 2015, ZIKV had spread to 18 other Brazilian states and rapidly became an epidemic, especially in northeastern Brazil.20,21 Circulating ZIKV in Brazil was identified as an Asian genotype through phylogenetic analyses of the envelope region in the 2 cases from Bahia.18 The only method to diagnose ZIKV infection is by real-time polymerase chain reaction, which is useful to detect the virus only in the first days of an acute infection. Real-time polymerase chain reaction is not helpful for confirming the infection in infants. Therefore, for now, ZIKV-related microcephaly is diagnosed clinically.22- 25 The frequency of cross-reactions with other flaviviruses (DENV, yellow fever virus) may make diagnosis difficult. Since April 2015, an epidemic of ZIKV has been occurring in Brazil. It is estimated that more than 1 million Brazilians have had ZIKV infections in 2015, reflecting the virus’ capacity to cause large-scale outbreaks where the biological vector is present.25,26 Six months after the onset of the ZIKV outbreak in Brazil, there was an unusual increase in newborns with microcephaly. In 2015, 1248 new suspected cases were registered, corresponding to a prevalence of 99.7 per 100 000 live births and representing a 20-fold increase compared with recent years.27 On January 4, 2016, the Brazilian Ministry of Health reported 3174 microcephalic newborns, the majority of whom were in Pernambuco and almost all in northeastern Brazil.28 The recent increase in the prevalence of microcephaly in several northeastern Brazilian states has been strongly suspected of being associated with ZIKV congenital infection, with the virus found in the amniotic fluid of 2 pregnant women whose newborns presented with a reduced head circumference.29 This serious effect of the ZIKV infection in fetuses is unsurprising considering the perinatal transmission reported for 2 women from French Polynesia and the strong neurotropism of the virus.1,14 In January 2016, Ventura et al30 published the first report of possible congenital ocular lesions in 3 infants from Recife, Pernambuco, Brazil. Recife is experiencing an outbreak of ZIKV infection as well as an increase in the number of newborns with microcephaly. The cases reported by Ventura and colleagues do not compose this case series. The aim of this study was to describe the ocular findings in 29 infants with microcephaly from mothers presumably infected with ZIKV during pregnancy, during an outbreak in Salvador, Bahia, Brazil. Key PointsQuestion: Are there ocular abnormalities in infants with microcephaly associated with presumed Zika virus congenital infection in Brazil? Findings: Congenital infection due to presumed Zika virus exposure was associated with vision-threatening findings; the majority of cases had bilateral macular and perimacular lesions as well as optic nerve abnormalities. Meaning: These data suggest that clinicians should consider ophthalmologic evaluations of newborns from regions in the Americas where Zika virus transmission has spread rapidly to identify lesions associated with this presumed Zika virus congenital infection.

ABSTRACTABSTRACT | INTRODUCTION | METHODS | RESULTS | DISCUSSION | CONCLUSIONS |ARTICLE INFORMATION | REFERENCES Importance The Zika virus (ZIKV) has rapidly reached epidemic proportions, especially in northeastern Brazil, and has rapidly spread to other parts of the Americas. A recent increase in the prevalence of microcephaly in newborn infants and vision-threatening findings in these infants is likely associated with the rapid spread of ZIKV. Objective To evaluate the ocular findings in infants with microcephaly associated with presumed intrauterine ZIKV infection in Salvador, Bahia, Brazil. Design, Setting, and Participants Case series at a tertiary hospital. Twenty-nine infants with microcephaly (defined by a cephalic circumference of ≤32 cm) with a presumed diagnosis of congenital ZIKV were recruited through an active search and referrals from other hospitals and health unities. The study was conducted between December 1 and December 21, 2015. Interventions All infants and mothers underwent systemic and ophthalmic examinations from December 1 through December 21, 2015, in the Roberto Santos General Hospital, Salvador, Brazil. Anterior segment and retinal, choroidal, and optic nerve abnormalities were documented using a wide-field digital imaging system. The differential diagnosis included toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus, syphilis, and human immunodeficiency virus, which were ruled out through serologic and clinical examinations. Main Outcomes and Measures Ocular abnormalities associated with ZIKV. Results Twenty-three of 29 mothers (79.3%) reported suspected ZIKV infection signs and symptoms during pregnancy, 18 in the first trimester, 4 in the second trimester, and 1 in the third trimester. Of the 29 infants (58 eyes) examined (18 [62.1%] female), ocular abnormalities were present in 17 eyes (29.3%) of 10 children (34.5%). Bilateral findings were found in 7 of 10 patients presenting with ocular lesions, the most common of which were focal pigment mottling of the retina and chorioretinal atrophy in 11 of the 17 eyes with abnormalities (64.7%), followed by optic nerve abnormalities in 8 eyes (47.1%), bilateral iris coloboma in 1 patient (2 eyes [11.8%]), and lens subluxation in 1 eye (5.9%). Conclusions and Relevance Congenital infection due to presumed ZIKV exposure is associated with vision-threatening findings, which include bilateral macular and perimacular lesions as well as optic nerve abnormalities in most cases.

Bruno de Paula Freitas, MD1; João Rafael de Oliveira Dias, MD2; Juliana Prazeres, MD2; Gielson Almeida Sacramento, BS3; Albert Icksang Ko, MD3,4; Maurício Maia, MD, PhD2; Rubens Belfort Jr, MD, PhD2[-] Author Affiliations1Department of Ophthalmology, Hospital Geral Roberto Santos, Salvador, Brazil 2Vision Institute, Department of Ophthalmology, Paulista Medical School, Federal University of São Paulo, São Paulo, Brazil 3Gonçalo Moniz Research Center, Oswaldo Cruz Foundation, Salvador, Brazil 4Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut JAMA Ophthalmol. Published online February 09, 2016. doi:10.1001/jamaophthalmol.2016.0267

Online First > Original Investigation | February 09, 2016Ocular Findings in Infants With Microcephaly Associated With Presumed Zika Virus Congenital Infection in Salvador, Brazilhttp://archopht.jamanetwork.com/article.aspx?articleid=2491896

Zika Virus – Feb. 9, 2016 Texas has 10 cases of Zika virus disease. Nine 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: Harris County – 7Bexar County – 1Dallas County – 2 DSHS encourages people to follow the U.S. Centers for Disease Control and Prevention (CDC) travel precautions for regions and certain countries where Zika virus transmission is ongoing. DSHS recommends travelers avoid mosquito bites while abroad and for seven days after returning, in case they have been exposed to Zika virus. People can protect themselves from mosquito bites by: Wearing long-sleeved shirts and long pantsUsing EPA-registered insect repellentsUsing permethrin-treated clothing and gearStaying and sleeping in screened-in or air-conditioned roomsRead more tips about mosquito bite prevention on the DSHS website. Visit the DSHS Spanish Zika page. Note: Zika case data for Texas will be updated weekdays by 11 a.m. http://www.texaszika.org/

MEXICO CITY, Mexico, in February. 8, 2016.- The number of registered cases of Zika in our country was raised to 65. According to the epidemiological bulletin of the Ministry of Health on Monday, the entity that has the largest number of laboratory confirmed cases is 35 Chiapas, Oaxaca after 21, and Nuevo Leon 4. Guerrero, Jalisco, Sinaloa, Veracruz and Yucatan Zika recorded a case of each. http://noticieros.televisa.com/mexico/1602/suman-65-casos-zika-mexico-35-chiapas/?platform=hootsuite

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

FOR IMMEDIATE RELEASE February 9, 2016 Contact: ODH Office of Communications (614) 644-8562 Cleveland Public Health Department (216) 664-7081 Ohio Reports First Zika Virus Case in Returning Traveler Zika virus tabletop exercise planning underway COLUMBUS – The Ohio Department of Health is reporting Ohio’s first case of Zika virus in a returning traveler from Haiti, a 30-year-old Cuyahoga County woman, city of Cleveland. The Centers for Disease Control and Prevention (CDC) was reporting 35 cases of Zika virus in 12 states and the District of Columbia prior to Ohio’s case. 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. Planning is underway for a Zika virus tabletop exercise to ensure Ohio’s preparedness at the local and state levels prior to the 2016 mosquito season that runs from May to October. 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. 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. “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,” said Dr. Mary DiOrio, medical director of the Ohio Department of Health. “There have been no reported cases of Zika virus disease transmission through mosquito bites anywhere in the continental U.S.” To prevent potential transmission through sexual contact, CDC recommends men with a pregnant sex partner abstain from sexual activity or consistently and correctly use condoms during sex for the duration of the pregnancy. CDC also recommends that pregnant women without symptoms of Zika virus disease be offered testing 2 to 12 weeks after returning from areas with ongoing Zika virus transmission. - more - CDC has issued a travel alert for people traveling to the following regions and countries where Zika virus transmission is ongoing: the Commonwealth of Puerto Rico and the U.S. Virgin Islands, U.S. territories; American Samoa; Barbados; Bolivia; Brazil; Cape Verde; Colombia; Costa Rica; Curaҫao; Dominican Republic; Ecuador; El Salvador; French Guiana; Guadeloupe; Guatemala; Guyana; Haiti; Honduras; Jamaica; Martinique; Mexico; Nicaragua; Panama; Paraguay; Saint Martin; Samoa; Suriname; Tonga; and Venezuela. Zika virus disease has historically occurred in Africa, Southeast Asia and islands in the Pacific Ocean. In May 2015, Zika virus was found for the first time in the Western Hemisphere in northeastern Brazil. The virus has since spread throughout much of the Caribbean, Central America and South America. The primary mosquito that transmits Zika virus is found in the tropics and southern U.S., but it is not established in Ohio. Another type of mosquito found in Ohio may potentially transmit Zika virus, although it has not yet been implicated in the transmission of human cases. “Prevention of mosquito-borne Zika virus transmission is the same as prevention of any other mosquitoborne diseases,” Dr. DiOrio said. “This includes taking precautions to prevent mosquito bites – such as using insect repellents, limiting exposure where and when mosquitoes are most active, and removing breeding sources such as containers that collect standing water.” For more information about the Zika virus, visit www.odh.ohio.gov/zika.

Ohio DoH cites Zika confirmation on Cleveland resident ex-Haiti. http://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/news/Ohio First Zika Virus Case 2016.pdf

ISDH: First case of Zika virus confirmed in IndianaStaff ReportsPublished: February 9, 2016, 9:42 am Updated: February 9, 2016, 9:49 amINDIANAPOLIS (WISH) – The Indiana State Department of Health announced that the first human case of the Zika virus was confirmed in Indiana on Tuesday. The CDC confirmed that the non-pregnant resident, who had recently traveled to Haiti, did not need to be hospitalized for treatment. State Health Commissioner Jerome Adams said the health department is providing guidance to local health officials and providers in anticipation of additional travel-related cases in Indiana. “The risk of contracting Zika virus here in Indiana remains low, but we know that many residents are concerned,” Dr. Adams said. “We urge anyone visiting affected areas to take steps to avoid mosquito bites.” There is currently an epidemic of the Zika virus infection occurring in Mexico, the Caribbean and Central and South America. Additional information about the virus and ways to protect yourself can be found by clicking here. http://wishtv.com/2016/02/09/isdh-first-case-of-zika-virus-confirmed-in-indiana/

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

(ISDH) First Human Case of Zika Virus Confirmed in IndianaStart Date: 2/9/2016Start Time: 12:00 AMEnd Date: 2/9/2016 inShare Entry DescriptionINDIANAPOLIS—State health officials today announced the first Indiana case of Zika virus infection in a non-pregnant resident who recently traveled to Haiti. This individual’s illness, which was confirmed by the Centers for Disease Control and Prevention (CDC), was not severe enough to require hospitalization. “I’m thankful for the work of the Indiana State Department of Health as they have tracked the spread of the Zika virus in Latin America and the Caribbean in the event it would arrive here in Indiana,” Governor Mike Pence said. “Hoosiers can be assured that the Department of Health is working diligently to study the latest information on the Zika virus and will be proactively keeping Hoosiers informed in the weeks and months ahead.” State Health Commissioner Jerome Adams, M.D., M.P.H., said the health department is providing guidance to local health officials and providers in anticipation of additional travel-related cases in Indiana. “The risk of contracting Zika virus here in Indiana remains low, but we know that many residents are concerned,” Dr. Adams said. “We urge anyone visiting affected areas to take steps to avoid mosquito bites.” There is currently an epidemic of Zika virus infection occurring in Mexico, the Caribbean and Central and South America. The virus is spread to people primarily through bites from an infected Aedes aegypti or Aedes albopictus mosquito. The CDC has also reported isolated cases of spread through unprotected sexual contact with an infected person. Most people who are infected with Zika virus won’t develop symptoms, but those who do are most likely to experience mild illness that can include fever, rash, joint pain and conjunctivitis (pink eye). There is no vaccine or treatment for Zika virus. Patients who think they might have Zika virus infection are asked to contact their health care providers and to avoid mosquito exposure for the first week of their illnesses to reduce the likelihood of transmission through mosquito bites. The CDC has advised pregnant women to avoid traveling to areas where Zika virus has been detected because of concern about birth defects. It also recommends that men who have a pregnant partner and reside in or have traveled to an area of active Zika virus transmission abstain from unprotected sexual activity for the duration of the pregnancy. Additional guidance can be found on the CDC’s Zika page at http://www.cdc.gov/zika/. People who choose to travel to Zika-affected areas are encouraged to take precautions against mosquito bites, including the following: Wear long-sleeved shirts and long pants to reduce the amount of exposed skin.Stay in places with air conditioning or that use window and door screens to keep mosquitoes outside. Sleep under a mosquito bed net if air conditioned or screened rooms are not available or if sleeping outdoors.Use Environmental Protection Agency (EPA)-registered insect repellents. When used as directed, these insect repellents are proven safe and effective even for pregnant and breastfeeding women.Look for products containing DEET, picaridin, oil of lemon eucalyptus, or IR3535 as the active ingredients.Always follow the product label instructions and reapply as directed.If you are using sunscreen, apply sunscreen before applying insect repellent.Treat clothing and gear with permethrin or buy permethrin-treated items.Do NOT use permethrin products directly on skin. They are intended to treat clothing."Pregnant women should not travel to areas where Zika virus transmission is occurring. Everyone else must weigh the risks against the benefits of travel and make the choice that feels right for them," said Dr. Jennifer Brown, public health veterinarian for the Indiana State Department of Health. "People who choose to travel can reduce their risk of Zika virus infection by taking rigorous precautions to prevent mosquito bites.” For a list of areas affected by the Zika virus, go tohttp://wwwnc.cdc.gov/travel/page/zika-travel-information. Dr. Brown will conduct a media availability to answer questions about Zika virus today from 11 a.m. to noon in Rice Auditorium at the Indiana State Department of Health, 2 N. Meridian St., Indianapolis. Media should sign in at the information desk upon arrival. Visit the Indiana State Department of Health at www.StateHealth.in.gov for important health and safety information, or follow us on Twitter at@StateHealthIN and on Facebook at www.facebook.com/isdh1. ### Contact Information: Name: Ken Severson Phone: 317.233.7104 Email: [email protected]

Indiana State Department of Health has confirmed Zika in a resident ex-Haiti. http://www.in.gov/activecalendar/EventList.aspx?view=EventDetails&eventidn=242289&information_id=237299&type=&syndicate=syndicate

Sequences producing significant alignments:Select:AllNone Selected:0 AlignmentsDownloadGenBankGraphicsDistance tree of resultsShow/hide columns of the table presenting sequences producing significant alignmentsSequences producing significant alignments:Select for downloading or viewing reportsDescriptionMax scoreTotal scoreQuery coverE valueIdentAccessionSelect seq gb|KU647676.1|Zika virus strain MRS_OPY_Martinique_PaRi_2015 polyprotein gene, complete cds1852518525100%0.0100%KU647676.1Select seq gb|KU509998.1|Zika virus strain Haiti/1225/2014, complete genome1840218402100%0.099%KU509998.1Select seq gb|KJ776791.1|Zika virus strain H/PF/2013 polyprotein gene, complete cds1839918399100%0.099%KJ776791.1Select seq gb|KU321639.1|Zika virus strain ZikaSPH2015, complete genome1839018390100%0.099%KU321639.1Select seq gb|KU365779.1|Zika virus strain BeH819966 polyprotein gene, complete cds1838118381100%0.099%KU365779.1Select seq gb|KU365780.1|Zika virus strain BeH815744 polyprotein gene, complete cds1836618366100%0.099%KU365780.1Select seq gb|KU365777.1|Zika virus strain BeH818995 polyprotein gene, complete cds1836318363100%0.099%KU365777.1Select seq gb|KU501217.1|Zika virus strain 8375 polyprotein gene, complete cds1835718357100%0.099%KU501217.1Select seq gb|KU501216.1|Zika virus strain 103344 polyprotein gene, complete cds1835418354100%0.099%KU501216.1Select seq gb|KU365778.1|Zika virus strain BeH819015 polyprotein gene, complete cds1834818348100%0.099%KU365778.1Select seq gb|KU312312.1|Zika virus isolate Z1106033 polyprotein gene, complete cds1834818348100%0.099%KU312312.1Select seq gb|KU501215.1|Zika virus strain PRVABC59, complete genome1833918339100%0.099%KU501215.1Select seq gb|JN860885.1|Zika virus isolate FSS13025 polyprotein gene, partial cds177571775799%0.098%JN860885.1Select seq gb|KF993678.1|Zika virus strain PLCal_ZV from Canada polyprotein gene, partial cds177241772498%0.099%KF993678.1Select seq gb|EU545988.1|Zika virus polyprotein gene, complete cds1760717607100%0.098%EU545988.1

Update equences producing significant alignments:Select:AllNone Selected:0 AlignmentsDownloadGenBankGraphicsDistance tree of resultsShow/hide columns of the table presenting sequences producing significant alignmentsSequences producing significant alignments:Select for downloading or viewing reportsDescriptionMax scoreTotal scoreQuery coverE valueIdentAccessionSelect seq gb|KU501216.1|Zika virus strain 103344 polyprotein gene, complete cds1852518525100%0.0100%KU501216.1Select seq gb|KU501217.1|Zika virus strain 8375 polyprotein gene, complete cds1852018520100%0.099%KU501217.1Select seq gb|KU509998.1|Zika virus strain Haiti/1225/2014, complete genome1839318393100%0.099%KU509998.1Select seq gb|KJ776791.1|Zika virus strain H/PF/2013 polyprotein gene, complete cds1839018390100%0.099%KJ776791.1Select seq gb|KU365779.1|Zika virus strain BeH819966 polyprotein gene, complete cds1838118381100%0.099%KU365779.1Select seq gb|KU321639.1|Zika virus strain ZikaSPH2015, complete genome1838118381100%0.099%KU321639.1Select seq gb|KU365780.1|Zika virus strain BeH815744 polyprotein gene, complete cds1836618366100%0.099%KU365780.1Select seq gb|KU365777.1|Zika virus strain BeH818995 polyprotein gene, complete cds1836318363100%0.099%KU365777.1Select seq gb|KU647676.1|Zika virus strain MRS_OPY_Martinique_PaRi_2015 polyprotein gene, complete cds1835418354100%0.099%KU647676.1Select seq gb|KU365778.1|Zika virus strain BeH819015 polyprotein gene, complete cds1834818348100%0.099%KU365778.1Select seq gb|KU312312.1|Zika virus isolate Z1106033 polyprotein gene, complete cds1834818348100%0.099%KU312312.1Select seq gb|KU501215.1|Zika virus strain PRVABC59, complete genome1833918339100%0.099%KU501215.1Select seq gb|JN860885.1|Zika virus isolate FSS13025 polyprotein gene, partial cds177571775799%0.098%JN860885.1Select seq gb|KF993678.1|Zika virus strain PLCal_ZV from Canada polyprotein gene, partial cds177031770398%0.099%KF993678.1Select seq gb|EU545988.1|Zika virus polyprotein gene, complete cds1759417594100%0.098%EU545988.1

Update Sequences producing significant alignments:Select:AllNone Selected:0 AlignmentsDownloadGenBankGraphicsDistance tree of resultsShow/hide columns of the table presenting sequences producing significant alignmentsSequences producing significant alignments:Select for downloading or viewing reportsDescriptionMax scoreTotal scoreQuery coverE valueIdentAccessionSelect seq gb|KU501217.1|Zika virus strain 8375 polyprotein gene, complete cds1852518525100%0.0100%KU501217.1Select seq gb|KU501216.1|Zika virus strain 103344 polyprotein gene, complete cds1852018520100%0.099%KU501216.1Select seq gb|KU509998.1|Zika virus strain Haiti/1225/2014, complete genome1839918399100%0.099%KU509998.1Select seq gb|KJ776791.1|Zika virus strain H/PF/2013 polyprotein gene, complete cds1839318393100%0.099%KJ776791.1Select seq gb|KU365779.1|Zika virus strain BeH819966 polyprotein gene, complete cds1838418384100%0.099%KU365779.1Select seq gb|KU321639.1|Zika virus strain ZikaSPH2015, complete genome1838418384100%0.099%KU321639.1Select seq gb|KU365780.1|Zika virus strain BeH815744 polyprotein gene, complete cds1837218372100%0.099%KU365780.1Select seq gb|KU365777.1|Zika virus strain BeH818995 polyprotein gene, complete cds1836618366100%0.099%KU365777.1Select seq gb|KU647676.1|Zika virus strain MRS_OPY_Martinique_PaRi_2015 polyprotein gene, complete cds1835718357100%0.099%KU647676.1Select seq gb|KU365778.1|Zika virus strain BeH819015 polyprotein gene, complete cds1835418354100%0.099%KU365778.1Select seq gb|KU312312.1|Zika virus isolate Z1106033 polyprotein gene, complete cds1835418354100%0.099%KU312312.1Select seq gb|KU501215.1|Zika virus strain PRVABC59, complete genome1834518345100%0.099%KU501215.1Select seq gb|JN860885.1|Zika virus isolate FSS13025 polyprotein gene, partial cds177621776299%0.098%JN860885.1Select seq gb|KF993678.1|Zika virus strain PLCal_ZV from Canada polyprotein gene, partial cds177061770698%0.099%KF993678.1Select seq gb|EU545988.1|Zika virus polyprotein gene, complete cds1759817598100%0.098%EU545988.1

New Zika hotspot feared in Colombia and VenezuelaANATOLY KURMANAEV, SARA SCHAEFER MUÑOZTHE WALL STREET JOURNALFEBRUARY 10, 2016 12:00AMSAVEPRINTA municipality worker prepares to fumigate a home to prevent the spread of Zika in Acapulco, Mexico. Health authorities say Zika is spreading quickly across Colombia and Venezuela, warning that the two countries’ porous border region could be the next hotspot for the mosquito-borne virus. Infectious-disease specialists say there are at least tens of thousands of cases across the two countries, which have a population of 80 million people. Health authorities say the virus is acute in the Colombian border city of Cucuta and flourishing in a string of towns and cities stretching north across steamy, swampy cattle fields and hamlets to Venezuela’s second-largest city, Maracaibo, near the Caribbean coast. The arrival of the virus, which produces generally mild symptoms but may be linked to a rare neurological disorder and to ­babies born with under-sized heads, is scaring people as it has in Brazil, where up to 1.5 million people may be infected. Dairy Varela, 19, four months pregnant, described feeling chills and aches as she sat in the waiting room of a clinic in San Jose­cito on the Venezuelan side of the border. She said doctors did not know what she had, since they lacked the supplies to test, but she bore hallmark signs of Zika. “Now my skin feels terrible, prickly, and I’m getting bumps on my arms and my face — see?” she said, pointing to a pink patch on her face. “I’m so scared. I’ve seen pictures on TV of those ­babies born with small brains.” Colombian health authorities have confirmed more than 20,000 cases of Zika, but they estimate there are 100,000 cases. They estimate the number of infections will grow to up to 700,000 this year. By the end of year, officials estimate, Colombia will have 500 cases of microcephaly, in which babies are born with under-sized heads and brains, and an extra 700 of Guillain-Barre syndrome, which can cause paralysis and death. Adding to the anxiety is the breakdown in Venezuela’s health system, which is starved for medicine and supplies amid the country’s economic meltdown. Mosquitoes do not respect international boundaries,” Fernando Ruíz, Colombia’s vice-minister of health, said last week . “We are concerned about what is happening in Venezuela, because Venezuela hasn’t done any epidemiological reports.” Last month, Venezuela’s Health Minister said authorities had identified 4700 cases of Zika, a figure that has drawn sharp criticism from medical associ­ations and infectious disease specialists in Venezuela and abroad. They say the real figure could be in the tens of thousands. “What we’re seeing now is a tip of the iceberg,” said Nellis Barbossa, chief epidemiologist for Zulia, the Venezuelan border state whose capital is Maracaibo. “We have an epidemic now.” Tours of a shantytown and hospital in Maracaibo, as well as poor communities along Venezuela’s northwest border with Colombia, left an impression that Zika was spreading unchecked. Venezuela lacks even aspirin and bug repellent, which doctors say are among the first lines of defence for viruses such as Zika. In Colombia, the Aedes mosquito that carries Zika is breeding fast. In one town there, El Zulia, residents say they are ­constantly surrounded by swarms of what they call “vampire mosquitoes”. “Practically everyone here has had Zika,” said Piedad Uribe, an administrator at a small hospital in El Zulia. Aleyda Zabaleta, a doctor at the hospital, logs each possible case of Zika, dispenses aceta­minophen and ibuprofen for pain and antihistamines for the virus’s stinging rashes. Pregnant women are referred to a larger hospital in Cucuta. Every morning, Dr Zabaleta leads a team that takes the hospital’s only ambulance into the small communities to treat ­people possibly infected by Zika and to advise them to get rid of the standing water where mosquitoes breed. “People need to know that the point of its origin is often mosquitoes breeding in the home,” she said. The Wall Street Journal http://www.theaustralian.com.au/business/wall-street-journal/new-zika-hotspot-feared-in-colombia-and-venezuela/news-story/e7ec318f8ae427d7cd587a769cefef9c

New Zika hotspot feared in Colombia and VenezuelaANATOLY KURMANAEV, SARA SCHAEFER MUÑOZTHE WALL STREET JOURNALFEBRUARY 10, 2016 12:00AMSAVEPRINTA municipality worker prepares to fumigate a home to prevent the spread of Zika in Acapulco, Mexico. Health authorities say Zika is spreading quickly across Colombia and Venezuela, warning that the two countries’ porous border region could be the next hotspot for the mosquito-borne virus. Infectious-disease specialists say there are at least tens of thousands of cases across the two countries, which have a population of 80 million people. Health authorities say the virus is acute in the Colombian border city of Cucuta and flourishing in a string of towns and cities stretching north across steamy, swampy cattle fields and hamlets to Venezuela’s second-largest city, Maracaibo, near the Caribbean coast. The arrival of the virus, which produces generally mild symptoms but may be linked to a rare neurological disorder and to ­babies born with under-sized heads, is scaring people as it has in Brazil, where up to 1.5 million people may be infected. Dairy Varela, 19, four months pregnant, described feeling chills and aches as she sat in the waiting room of a clinic in San Jose­cito on the Venezuelan side of the border. She said doctors did not know what she had, since they lacked the supplies to test, but she bore hallmark signs of Zika. “Now my skin feels terrible, prickly, and I’m getting bumps on my arms and my face — see?” she said, pointing to a pink patch on her face. “I’m so scared. I’ve seen pictures on TV of those ­babies born with small brains.” Colombian health authorities have confirmed more than 20,000 cases of Zika, but they estimate there are 100,000 cases. They estimate the number of infections will grow to up to 700,000 this year. By the end of year, officials estimate, Colombia will have 500 cases of microcephaly, in which babies are born with under-sized heads and brains, and an extra 700 of Guillain-Barre syndrome, which can cause paralysis and death. Adding to the anxiety is the breakdown in Venezuela’s health system, which is starved for medicine and supplies amid the country’s economic meltdown. Mosquitoes do not respect international boundaries,” Fernando Ruíz, Colombia’s vice-minister of health, said last week . “We are concerned about what is happening in Venezuela, because Venezuela hasn’t done any epidemiological reports.” Last month, Venezuela’s Health Minister said authorities had identified 4700 cases of Zika, a figure that has drawn sharp criticism from medical associ­ations and infectious disease specialists in Venezuela and abroad. They say the real figure could be in the tens of thousands. “What we’re seeing now is a tip of the iceberg,” said Nellis Barbossa, chief epidemiologist for Zulia, the Venezuelan border state whose capital is Maracaibo. “We have an epidemic now.” Tours of a shantytown and hospital in Maracaibo, as well as poor communities along Venezuela’s northwest border with Colombia, left an impression that Zika was spreading unchecked. Venezuela lacks even aspirin and bug repellent, which doctors say are among the first lines of defence for viruses such as Zika. In Colombia, the Aedes mosquito that carries Zika is breeding fast. In one town there, El Zulia, residents say they are ­constantly surrounded by swarms of what they call “vampire mosquitoes”. “Practically everyone here has had Zika,” said Piedad Uribe, an administrator at a small hospital in El Zulia. Aleyda Zabaleta, a doctor at the hospital, logs each possible case of Zika, dispenses aceta­minophen and ibuprofen for pain and antihistamines for the virus’s stinging rashes. Pregnant women are referred to a larger hospital in Cucuta. Every morning, Dr Zabaleta leads a team that takes the hospital’s only ambulance into the small communities to treat ­people possibly infected by Zika and to advise them to get rid of the standing water where mosquitoes breed. “People need to know that the point of its origin is often mosquitoes breeding in the home,” she said. The Wall Street Journal http://www.theaustralian.com.au/business/wall-street-journal/new-zika-hotspot-feared-in-colombia-and-venezuela/news-story/e7ec318f8ae427d7cd587a769cefef9c

Zika expert: ‘Microcephaly may just be the tip of the iceberg.’By Lena H. Sun February 9 at 7:00 AM A 6-week-old baby born with microcephaly is treated at a clinic in Recife, Pernambuco state, Brazil. (Mario Tama/Getty Images)Albert Ko, an epidemiologist and infectious disease expert at the Yale University School of Public Health, has been studying Zika virus and its link to birth defects in newborns in Brazil. The mosquito-borne virus is suspected in a huge increase in cases of microcephaly, a rare condition in which babies have unusually small heads and damaged brains. Ko spent December in Salvador, Brazil’s third largest city, working with researchers from the Oswaldo Cruz Foundation, a branch of that country's health ministry, and from the University of Texas Medical Branch in Galveston. The team was investigating microcephaly cases at three maternity hospitals. The Washington Post spoke with Ko on two occasions; his answers have been edited for clarity and length. What has your research found so far at these three hospitals? We are still in the middle of our investigation. We strongly believe that the cases of microcephaly we are identifying during this outbreak are due to Zika virus. However, there are important caveats. First, it’s very likely that because of the high surveillance, we’re identifying cases that would not normally be reported or identified. Secondly, we still need to confirm that Zika virus is causing the large majority of the cases. Brazilian researchers have shown that Zika virus can cause congenital infections, and they have detected the virus in tissues of stillbirths as well as fetuses with congenital malformations. But for the large majority of cases that have been reported as microcephaly, we still don’t have firm evidence. This is one of the primary objectives of our research. Jose Wesley, who suffers from microcephaly, sleeps on a large pillow on his mother's bed in Bonito, Pernambuco state, Brazil. (AP Photo/Felipe Dana)How many babies have been born with suspected cases of microcephaly at these hospitals? We have identified both stillbirths and live births. We have identified 100 live births. But not all of those [cases] may be caused by Zika. We are trying to rule out other common causes, such as prematurity and congenital infections, including toxoplasmosis (an infection caused by a parasite commonly found in cat feces or cat litter). Can you describe the different kinds of birth defects you’re seeing? We’re seeing a spectrum. Many have fairly severe central nervous system lesions. There are also a lot of calcium deposits. … Those can cause seizures and cause impairment in terms of function for the brain. We’re also seeing that in some babies, the brains, which usually have wrinkles, are actually smooth. That’s a sign that development of the brain has been impaired. Several of them are also impaired with respect to vision and hearing. What else are you finding? It seems like microcephaly may just be the tip of the iceberg. The preliminary evidence is that [some] babies who don’t have microcephaly may also have neurological lesions or birth defects that are not as obvious as microcephaly. We’re really concerned because of Zika, but we need to rule out other causes of congenital infection to really make sure. How are the parents and families handling the stress and anxiety? Obviously there’s a large amount of fear, especially among pregnant women. … For many people, the level of anxiety is extremely great. People want a birth. It’s one of the greatest pleasures or expressions of love in a person’s life. … For many of the families, it really hasn’t hit yet what the future is going to be. Not all the brains are severely compromised. Some of the babies, now one month or two months old, they’re feeding, they’re growing. There is a wide mix of emotions. Some families are in denial. Some are just devastated. All of the physicians are just feeling the enormous weight of seeing this unfold, the uncertainty of what has caused this and what the future holds for these babies. There’s a strange heaviness across all the physicians. Once individuals are infected, do they have immunity for life? We know so little. We presume that like other flaviviruses, except for dengue, if you’ve been exposed, you will have long-term immunity to being reinfected. https://www.washingtonpost.com/news/to-your-health/wp/2016/02/09/zika-expert-microcephaly-may-just-be-the-tip-of-the-iceberg/

5 people in PA test negative for Zika virus, 14 tests pending BY BEN SCHMITT | Monday, Feb. 8, 2016, 5:42 p.m. Email NewslettersSign up for one of our email newsletters. Updated 6 hours ago 5 in Pa. test negative Five Pennsylvania residents have tested negative for the Zika virus, and 14 test results for others are pending, the state Department of Health said Monday. The Health Department announced last week that it intends to release local updates every Monday. No locally transmitted Zika cases have been reported in the United States. The illness has been reported in travelers returning from affected countries. The Pennsylvania residents in question recently traveled out of the country, health officials said. The primary mosquito that carries Zika is not found in Pennsylvania, experts said. However, the Asian tiger mosquito, a secondary type of mosquito that can carry the disease, has been found in the state. There is no cure for the Zika virus, and no vaccine can prevent it. In many cases, symptoms are mild or go unnoticed, experts said. Zika primarily spreads through mosquito bites, and symptoms include fever, rash, joint pain and red eyes. — Tribune-Review staff writerBen Schmitt http://triblive.com/news/adminpage/9941363-74/zika-health-mosquito