From: Williams, Carl [mailto:email@example.com]
Sent: Thursday, January 28, 2016 9:12 AM
Subject: [phleaders] Guidance for Zika Virus Diagnosis, Management and Reporting
Please see the attached guidance pertaining to Zika virus diagnosis, management and reporting. We have consolidated a great deal of information from the Centers for Disease Control, The American Congress of Obstetricians and Gynecologists, and the Pan American Health Organization. As you are no doubt aware this is a rapidly changing situation so please stay tuned for updates. CDC will post their latest updates at http://www.cdc.gov/zika/. The Division of Public Health is also developing web content related to Zika virus so please check in for material there as well http://epi.publichealth.nc.gov/cd/.
Please feel free to call the Communicable Disease Branch at 919-733-3419 with any questions
Carl Williams, DVM, DACVPM
State Public Health Veterinarian
Division of Public Health, Communicable Disease Branch
North Carolina Department of Health and Human Services
January 28, 2016
To: North Carolina Health Care Providers and Laboratories
From: Megan Davies, MD, State Epidemiologist
Scott Zimmerman, DrPH, MPH, HCLD (ABB), State Laboratory of Public Health
Belinda Pettiford, MPH, Women’s Health Branch
Subject: Zika Virus Diagnosis, Management and Reporting (3 pages)
This memo is intended to provide information to NC clinicians and laboratories regarding diagnosis, management and reporting of Zika virus infection.
Zika is a mosquito-borne virus that is currently causing a large outbreak in Brazil, including reports of pregnant women giving birth to babies with birth defects. Zika virus was first identified in Uganda in 1947 and is transmitted by Aedes aegypti and A. albopictus mosquitos. Since 2007, Zika virus has caused large outbreaks in Gabon, Micronesia and French Polynesia. Since 2015, endemic transmission has been occurring in Central and South America. A map of affected areas is available at http://www.cdc.gov/zika/geo/index.html. To date, only travel-associated cases have been identified in the United States. No cases have been reported in North Carolina.
Clinical and Epidemiologic Features:
Approximately 1 in 5 people infected with Zika virus become ill. Symptoms begin about 3–12 days after exposure, last between 2 and 7 days and include mild fever, rash (mostly maculopapular), headaches, arthralgia, myalgia, and non-purulent conjunctivitis. Patients may remain viremic for up to 7 days after symptom onset. Clinical symptoms are often similar to dengue and chikungunya infections.
Because of similar geographic distribution and symptoms, patients with suspected Zika virus infections also should be evaluated and managed for possible dengue or chikungunya infection. Similar to dengue and chikungunya infections, no specific antiviral treatment is available for Zika virus infection. Treatment is generally symptomatic and can include rest, fluids, and use of acetaminophen. Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs), like ibuprofen and naproxen, should be avoided until dengue can be ruled out to reduce the risk of hemorrhage.
Zika Virus Infection and Pregnancy:
Due to reports of microcephaly and other poor outcomes in babies of mothers who were infected with Zika virus while pregnant, the CDC recommends that pregnant women consider postponing travel to areas where Zika virus transmission is ongoing. Pregnant women and women trying to become pregnant who do travel to these areas should talk to their healthcare providers first and strictly follow steps to avoid mosquito bites during their trip.
Health care providers should ask all pregnant women about recent travel. Pregnant women who develop symptoms consistent with Zika virus infection within two weeks of travel to an area with ongoing transmission should be evaluated by a health care provider and recommended for testing as described below.
CDC and the American Congress of Obstetricians and Gynecologists (ACOG) recommend that an ultrasound evaluation be performed for asymptomatic pregnant women reporting travel at any time during pregnancy to an area with ongoing transmission in order to detect fetal microcephaly or intracranial calcifications. Serial ultrasound screening (every 3-4 weeks) may be considered at the discretion of the provider. Additional recommendations for management of pregnant women with travel history to an area with ongoing Zika virus transmission are available at http://www.cdc.gov/zika/pdfs/questions-answers-clinicians.pdf and https://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Interim-Guidance-for-Care-of-Obstetric-Patients-During-a-Zika-Virus-Outbreak.
Recommendations for additional assessment and laboratory testing for infants with possible congenital Zika virus infection are available at http://www.cdc.gov/zika/hc-providers/qa-pediatrician.html.
Testing for Zika virus should be conducted in consultation with the state and local public health for the following individuals:
· Pregnant women presenting with signs and symptoms consistent with Zika virus disease (acute onset of fever, maculopapular rash, arthralgia, or conjunctivitis) within two weeks of travel to an area with ongoing transmission, or
· Asymptomatic pregnant women who have ultrasound findings of fetal microcephaly or intracranial calcifications and who report travel to an area with ongoing transmission during pregnancy.
· Patients presenting with signs and symptoms consistent with Zika virus disease (acute onset of fever, maculopapular rash, arthralgia, or conjunctivitis) within two weeks of travel to an area with ongoing transmission.
Approval is required for submission of specimens. Please contact the Communicable Disease Branch at 919-733-3419 or your local health department to facilitate testing if Zika virus infection is suspected.
Because of concurrent circulation of Zika, dengue, and chikungunya viruses and the similarity of illness presentation, CDC recommends concurrent testing for all three viruses in patients with a recent history of travel to an affected area and clinically compatible illness.
Appropriate testing is determined based on how long after symptom onset the specimen is collected.
· Specimens collected <4 days after symptom onset will be subjected to molecular testing (RT-PCR) for all three viruses.
· Specimens collected 4–7 days after symptom onset will be subjected to molecular testing and serologic testing for virus-specific IgM antibodies. Because serum collected within 7 days of illness onset may not have detectable virus-specific IgM antibodies, IgM testing should be repeated on a convalescent-phase sample.
· Specimens collected >7 days after symptom onset will be subjected to serologic testing for virus-specific IgM antibodies.
Where to test
Testing for Zika, dengue, and chikungunya viruses will be coordinated by the NC State Laboratory of Public Health (NCSLPH) and conducted in collaboration with CDC. The provider for each patient should complete the following forms:
· The NCSLPH submission form DHHS 3445, which is available at http://slph.state.nc.us/virology-serology/special-serology.asp. (At the bottom of this form, please check “Forward to CDC” and write in specific tests requested. NCSLPH will perform chikungunya molecular and serological testing with a 6 business day turn-around-time.)
· The CDC 50.34 DASH form, which is available at http://slph.ncpublichealth.com/Forms/CDC-5034-DashForm-120515.pdf. This form must be completed online and then printed. Be sure to use ‘Test Order Name’ as ‘Arbovirus Serology.’
Because of the extensive cross-reactivity between the Flaviviruses, the following information must be provided with submitted specimens:
· Travel history, onset date, specimen collection date, specimen type, description of clinical illness, vaccination history (specifically yellow fever and Japanese encephalitis vaccines), and submitter contact information.
· When submitting perinatal specimens or specimens collected from pregnant women, please include the gestational age of the fetus at the time of travel.
Submitters should also request testing for all three viruses on both test request forms. Both forms should be completed for all specimens, acute and convalescent, and should be submitted to the NC SLPH.
Table: specific specimen collection, testing, and shipment information for Zika, Chikungunya and Dengue Testing:
|Specimen||Test Performed||Specimen Volume||Shipment|
|Serum||Chikungunya RT-PCR & IgM;
Zika and Dengue RT-PCR and virus-specific IgM;
|2–5 mL serum||Refrigerated (4°C), placed on cold packs if shipment is to be received within 72 hrs of collection. For delays exceeding 72 hrs, freeze at -70°C & ship on dry ice.|
|Amniotic Fluid*||Zika RT-PCR||0.5–3 ml||Refrigerated (4°C), placed on cold packs if shipment is to be received within 72 hrs of collection. For delays exceeding 72 hrs, freeze at -70°C & ship on dry ice.|
|Cord Blood||Zika RT-PCR & IgM; Flavivirus PRNT||0.5–3 ml||Refrigerated (4°C), placed on cold packs|
|Placental Tissue||Zika RT-PCR;
|2–5 grams||Freeze at -70°C & ship on dry ice.|
|Placental Tissue and Umbilical Cord||Immunohistochemical Staining & Zika virus RT-PCR||2–5 grams of tissue and/or paraffin blocks||Tissue should be formalin-fixed or paraffin-embedded. Ship specimens at room temperature.
Note: Request consultation with NCSLPH for specific instructions.
*Patient and healthcare provider must weigh risks and benefits of testing prior to collection of amniotic fluid.
Contact the NCSLPH at 919-807-8600 prior to any shipment or if you have questions. All specimens should be shipped as a Category B Biological Substance.
Addressall specimen shipments as follows: Attention: Virology/Serology Unit
North Carolina State Laboratory of Public Health
4312 District Drive
Raleigh, NC 27607-5490
Surveillance and Reporting:
Please contact the Communicable Disease Branch at 919-733-3419 or your local health department if Zika virus infection is suspected. As a reminder, dengue and chikungunya infections are specifically reportable per 10A NCAC 41A .0101.
This is an evolving situation and recommendations are likely to change as new information becomes available. Updated information and guidance are available from CDC at http://www.cdc.gov/zika.