1. Zika Virus Infection Thomas M. File, Jr. M.D., M.Sc.
Chair, Infectious Disease Division
Summa Health System;
Professor of Internal Medicine,
Chair Infectious Disease Section
Northeast Ohio Medical University

5. Fever in Traveler returning from Caribbean
Returning traveler from the Caribbean(5 days)
Within 24 hours c/o pain to back of knees, both ankles and feet, wrists and hands-symmetric, no swelling nor erythema, lasted 3-4 days
Severe spinal pain, inability to stand upright -3 days
Fevers –constant for up to 72 hours F
Malaise, myalgia, fatigue for 1 week
2-3 days later, faint erythema to trunk, followed by photosensitivity rash to arms face legs-transient pruritus
No headaches, URI symptoms

6. Chikungunya Viral infection No person-to-person transmission
No vaccine or treatment
No person-to-person transmission
Mosquito vectors
Aedes aegypti or Aedes albopictus widespread
Mosquitoes can “hitchhike”

8. Chikungunya The mosquitoes Symptoms
Aedes species; same types for dengue virus
Bite mostly during the daytime
Symptoms
Usually begin 3‒7 days after being bitten by an infected mosquito
Most common symptoms are fever and severe joint pains, often in the hands and feet
Joint pains persist in 50% for > 1 year
Other symptoms may include headache, muscle pain, joint swelling, or rash

9. Chikungunya
Sudden high fever (usually >102º F) which may be continuous or intermittent
Severe joint pain that commonly involves the hands and feet
Joint swelling
Back pain
Rash usually 2-5 days after fever starts
Other symptoms may include headache, body ache, nausea, vomiting, and redness around the eyes. In unusual cases, infection can involve the brain, eyes, heart, kidney and other organs. 
Fatal infections are rare, however many patients have chronic joint pain, arthritis, loss of energy and depression lasting weeks to years.

10. Differential diagnosis
Chikungunya vs Dengue viral fever
Dengue more pronounced retro-orbital pain
More commonly hypotension and mild bleeding complications
Fatigue can last for months
Associated with higher mortality
?influenza-like, but no URI symptoms
Outbreak Dengue in Hawaii (Nov, 2015, Big Island)

11. Diagnostic testing Performed on the 3rd day given persistent symptoms
CBC, mild lymphopenia, mild thrombocytopenia
LFT not done
Mild CPK elevation
Chikungunya PCR+
Other options: paired sera for Chikungunya IgM

12. Treatment/Prevention
Chikungunya
Treatment/Prevention
No medication to treat or prevent infection
Vaccine under development
Reduce mosquito exposure
Use air conditioning or window/door screens
Use mosquito repellents on exposed skin. Repellents containing DEET, picaridin, IR3535, and some oil of lemon eucalyptus and para-menthane-diol products provide long lasting protection.
Wear long-sleeved shirts and long pants
Empty standing water from outdoor containers
Support local vector control programs

13. Flaviviridae virus family; related to dengue, West Nile, Chikungunya
Started Uganda; new to West Hemisphere, Fla…..
Transmission: Mosquitoes, Sexual contact, ?other
Incubation: 2-12 days
Only 1 in 5 people infected with Zika virus experience symptoms
fever, rash, joint pain and conjunctivitis, and sometimes headaches, muscle pain and vomiting. The illness lasts about a week.
linked to some alarming complications-microcephaly in fetuses of infected pregnant women; Guillan Barre Syndrome…….
Test: PCR of blood (within 7-14 days illness); Serology (after 14 days)

16. TRANSMISSION

17. Zika Virus Clinical Course
Clinical course usually mild
Symptoms last several days to a week
Severe disease requiring hospitalization infrequent
Fatalities rare
Neurologic sequelae uncommon

18. Neurologic manifestations of Zika virus
Burden higher than Microcephaly
Other Childhood concerns
Other neurological sequelae:
GBS
Encephalitis
Myelitis
Acute disseminated encephalomyelitis (ADEM)
Opsoclonus-myoclonus-ataxia syndrome( OMS)
James J. Sejvar, MD, Neuroepidemiologist CDC. Nov 11, 2016

19. ZIKA SYMPTOMS
Typically starts on face ; spreads

21. NEJM March 3, 2016

23. ZIKA: Therapy Prevention

30. 72 Pregnant women + Zika; 5-38 wks gestation Pred features;
pruritic descendng rash (maculopapulrar), arthralgia, HA; 28% fever, lymphadenopthy
42 with fetal US
Abn in 12 (29%)
Fetal death-2
Growth restriction with or without microcephaly- 5
CNS lesions- 7; ABN cerebral or umbilical artery flow-7
Conclusion: Despite mild clinical symptoms, ZIKV infection during pregnancy appears to be associated with grave outcomes, including fetal death, placental insufficiency, fetal growth restriction, and CNS injury
NEJM March 3, 2016

31. NEJM March 3, 2016

32. Zika and Microcephaly: US
Report from CDC 2/25/2016
9 woman with + tests (of 257 tested)
3 delivered: 2 healthy, 1 microcephaly
2 had miscarriages
2 abortions: one with microcephaly
2 pregnancies continuing
2 of nine delivered healthy babies, but two still pregnant
2 confirmed microcephaly

33. Zika: US Report 10/26/2016 Total 32,814 99% in territories: PR, VI….
Locally acquired: 28,289
99% in territories: PR, VI….
139 in FLA
Travel related 4048
Preg outcomes in 50 US States
25 births with defects.

35. CDC Recommendations: Pregnancy
If pregnant avoid travel to areas of Zika infection
Male partners to areas should abstain or use condoms during entire pregnancy if traveled to area of Zika infection; avoid impregnation for 6 months
If Pregnant and has traveled to area of Zika infection
See algorithm next slide
If not pregnant but child bearing age and going to area of Zika infection
Use reliable birth control (50% pregnancies in US unplanned)
Mosquito avoidance
Avoid pregnancy 2 months

37. ZIKA Vaccine Under Development
In June 2016 the FDA granted the first approval for a human clinical trial for a Zika vaccine.

38. Healio Outbreak Tracker. Nov 24, 2016

39. Healio Outbreak Tracker. Nov 28, 2016