1. Zika and STI Transmission Clinical Case Study 2 Angélica Espinosa Miranda Universidade Federal do Espirito Santo Departamento de Medicina Social 17th IUSTI World Congress Marrakesh, 9-12 May, 2016

2. Aedes: vector of Zika virus Muhammad Mahdi Karim (www.micro2macro.net) It is a vector for Zika virus, yellow fever, dengue, Chikungnuya, West-Nile and Japanese encephalitis viruses. Only the female bites for blood, which she needs to mature her eggs, mainly in day time. A.africanus; A. albopictus; A. aegypti; A. hensilli; A. polynesiensis; A. luteocephalus; A. vitattusi.

3. Zika virus Arthropod- borne-virus Flavivirus gen Flaviviridae family Spondweni group Illustration of Zika virus in blood: Kateryna Kon/Science Photo Library

4. Zika Forest 1947 Dick, Trans R Soc Trop Med Hyg.1952

5. Zika - Epidemiology 1952: Uganda - 6.1% prev. antibodies against Zika 1953: Nigeria - human cases 2007: Yap islands, Micronesia 185 suspected cases 49 confirmed cases 59 probable cases No serious cases MacNamara, Trans R Soc Trop Med Hyg.1954 Dick, Trans R Soc Trop Med Hyg.1953 Duffy et al, N Engl J Med. 2009

6. Zika - Epidemiology 2013: French Polynesia 8,510 suspected cases and 396 confirmed cases Neurologic complications: 72 cases 40 cases of Guillain-Barre syndrome 1% of microcephaly 2015: Brazil Northeastern region: 77.2% of cases 91,300 suspected cases – 7,584 in pregnant women 1,168 confirmed cases of microcephaly and 3,741 under investigation Brazilian MoH, 2016; Campos et al, Emerg Infect Dis 2016 Cao-Lormeau et al, Emerg Infect Dis 2013; Oehler et al, Euro Surveill 2014; Cauchemez et al Lancet 2016

7. Source: CDC, May 5, 2016

8. WHO. ZIKA VIRUS MICROCEPHALY AND GUILLAIN-BARRÉ SYNDROME SITUATION REPORT 21 APRIL 2016

9. Confirmed cases of microcephaly in states of Brazil (583 cases reported up to 20 February 2016)

10. Symptoms: Dengue, Chikungunya & Zika Adapted from Dr. Carlos Brito – UFPE, Brazil

11. Conjunctival hyperemia HUCAM

13. Costa et al, Ann Intern Med.2016 Microcephaly SMSPe

14. Zika diagnosis Molecular techniques such as reverse-transcription polymerase chain reaction (RT-PCR) and quantitative real-time PCR (qRT-PCR) using virus-specific probes Lanciotti et al, Emerg Infect Dis 2008; Balm et al, J Med Virol. 2012 The viraemic period is short, allowing for molecular virus detection in blood samples during the first 5 days after onset of symptoms Lanciotti et al, Emerg Infect Dis 2008; Faye et al, J Clin Virol. 2008

15. Zika diagnosis Specific Zika IgM antibodies can be detected by enzyme- linked immunosorbent assay (ELISA) or immuno- fluoresecence assays (IFA) from day 4 to 5 after onset of symptoms. Lanciolli et al, Emerg Infect Dis 2008; Euro Surveill, 2016 As a significant cross reactivity of IgM/IgG antibodies among flaviviruses exists, such as for dengue (4 serotypes), West Nile viruses and yellow fever, additional testing for laboratory confirmation is required. Lanciolli et al, Emerg Infect Dis 2008; Euro Surveill, 2016

16. Provisional overview of laboratory tests for Zika virus diagnostic Euro Surveill, 2016

17. Zika & sexual transmission Recent data showed the presence of Zika virus in blood, semen, urine and saliva. It suggests the transmission could be also by these corporal fluids. Lanciolli et al, Emerg Infect Dis 2008; Gourinat et al, Emerg Infect Dis 2015; Musso et al, Emerg Infect Dis 2015-B; Atkinson et al, Emerg Infect Dis 2016; CDC, 2016 Zika can be transmitted from a man to his sex partners. Oster et al, MMWR 2016; Musso et al, Emerg Infect Dis 2015 As of April 2016 sexual transmission of Zika has been documented in several countries Argentina, Chile, France, Italy, New Zealand, USA, Canada – during the 2015 outbreak. WHO, 2016; CDC, 2016

18. What we know Zika virus can be spread during sex by a man infected with Zika to his partners. Musso et al, Emerg Infect Dis 2015; Atkinson et al, Emerg Infect Dis2016 In known cases of sexual transmission, the men had Zika symptoms. From these cases, we know the virus can be spread when the man has symptoms, before symptoms start, and after symptoms end. Musso et al, Emerg Infect Dis 2015 The virus can stay in semen longer than in blood.

19. What we know Two studies demonstrated Zika viral RNA in semen up to 62 days after onset of symptoms and found infectious Zika virus in semen more than three weeks after onset of Zika symptoms. Musso et al, Emerg Infect Dis 2015; Atkinson et al, Emerg Infect Dis 2016 Zika viral RNA has been detected in urine more than 10 days after onset of disease. Gourinat et al, Emerg Infect Dis 2015; Campos et al, Emerg Infect Dis 2016; Rozé et al, Euro Surveil 2016; Shinohara et al, J Travel Med 2016 And in saliva (for up to 6 to 8 days after onset of symptoms). Musso et al, Emerg Infect Dis 2015-B

20. Reported cases USA: A biologist who had been bitten many times while studying mosquitoes in Senegal. Six days after returning USA in August 2008, he fell ill with symptoms of Zika fever but not before having unprotected intercourse with his wife, who had not been outside the country in 2008. She developed symptoms of Zika fever, and Zika antibodies in both the biologist's and his wife's blood confirmed the diagnosis. Foy et al, Emerg Infect Dis. 2011

21. Reported cases French Polynesia: In 2014, Zika capable of growth in lab culture was found in the semen of a man at least two weeks (and possibly up to 10 weeks) after he fell ill with Zika fever. During the ZIKV outbreak, a 44-year-old man in Tahiti had symptoms of ZIKV infection: asthenia, low grade fever and arthralgia. Symptoms lasted 3 days. Two weeks after a second episode, he noted signs of hematospermia and sought treatment. Musso et al, Emerg Infect Dis. 2015

22. Reported cases United Kingdom: In 2014, a 68-year-old man had onset of fever, marked lethargy, and an erythematous rash 1 week after returning from the Cook Islands. Serum samples taken 3 days into the febrile illness tested positive for Zika virus by RT-PCR. Semen was positive for by RT-PCR, 27 and 62 days after onset of febrile illness. Atkinson et al, Emerg Infect Dis 2016

23. Reported cases USA: Report of transmission of Zika virus from an infected man to a sex partner through anal sex. A man in USA with recent travel to an area of active Zika virus transmission and his non traveling male partner. Deckard et al, MMWR 2016 As of April 2016 fourteen additional cases of possible sexual transmission have been under investigation in seven no endemic countries.

24. Zika & sexual transmission Before these reports, no arboviruses had been isolated from human semen. There are a lot unanswered questions and, for now, it is important to be cautious. It rest assured that the real threat of Zika virus is still mosquitoes.

25. Zika & sexual transmission No treatment and no vaccine Recommendation of condom use and counseling are important. In endemic countries, It is not likely that sexual transmission is anywhere close to the frequency of mosquito-borne transmission of Zika virus.

26. VECTOR CONTROL

27. Zika sexual transmission: CONDOM

28. http://stihivrio2017.com