ZIKA VIRUS
SITUATION REPORT ZIKA VIRUS MICROCEPHALY GUILLAIN-BARRÉ SYNDROME 30 JUNE 2016 As of 29 June 2016, 61 countries and territories report continuing mosquito-borne transmission (Fig. 1) of which: 47 countries are experiencing a first outbreak of Zika virus since 2015, with no previous evidence of circulation, and with ongoing transmission by mosquitos (Table 1). 14 countries reported evidence of Zika virus transmission between 2007 and 2014, with ongoing transmission. In addition, four countries or territories have reported evidence of Zika virus transmission between 2007 and 2014, without ongoing transmission: Cook Islands, French Polynesia, ISLA DE PASCUA – Chile and YAP (Federated States of Micronesia)1. Ten countries have reported evidence of person-to-person transmission of Zika virus, probably via a sexual route (Table 2). In the week to 29 June 2016, no new country or territory has reported mosquito-borne Zika virus transmission. As of 29 June 2016, microcephaly and other central nervous system (CNS) malformations potentially associated with Zika virus infection or suggestive of congenital infection have been reported by thirteen countries or territories. Three of those countries reported microcephaly cases born from mothers with a recent travel history to Zika affected countries in Latin America (Table 3). As of 16 June, the United States Centers for Disease Control and Prevention (US-CDC) reported four live born infants with birth defects and four pregnancy losses with birth defects with laboratory evidence of possible Zika virus infection2. In addition, a baby with microcephaly was born in the United States of America to a mother who is a resident of Haiti 3. On 20 June 2016, French Guiana reported the first case of congenital microcephaly associated with Zika virus infection in a pregnant woman. Microcephaly in the fetus has been diagnosed through ultrasound, and the amniotic fluid tested positive for Zika virus by RT-PCR 4.
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Kosrae has recently reported mosquito-borne Zika virus transmission. However, Yap has reported an outbreak in 2007 that has terminated. Both island states are part of the Federated States of Micronesia. 2 https://www.cdc.gov/zika/geo/pregnancy-outcomes.html 3 http://www.floridahealth.gov/newsroom/2016/06/062816-zika-update.html 4 Reverse transcription polymerase chain reaction (RT-PCR).
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In the context of Zika virus circulation, 14 countries and territories worldwide have reported an increased incidence of Guillain-Barré syndrome (GBS) and/or laboratory confirmation of a Zika virus infection among GBS cases (Table 4). Zika infection was diagnosed in one patient with GBS and six others are under investigation in Guadeloupe 5. Based on research to date, there is scientific consensus that Zika virus is a cause of microcephaly and GBS. Sequencing of the virus that causes the Zika outbreak in Cabo Verde showed that the virus is of the Asian lineage and the same as the one that circulates in Brazil. The third meeting of the Emergency Committee (EC) convened by the Director-General under the International Health Regulations (2005) regarding microcephaly, other neurological disorders and Zika virus was held by on 14 June 20166. The global Strategic Response Framework launched by the World Health Organization (WHO) in February 2016 encompasses surveillance, response activities and research. An interim report7 has been published on some of the key activities being undertaken jointly by WHO and international, regional and national partners in response to this public health emergency. A revised strategy for the period of July 2016 to December 2017 was published on 17 June8. WHO has developed new advice and information on diverse topics in the context of Zika virus9. WHO’s latest information materials, news and resources to support corporate and programmatic risk communication, and community engagement are available online10. Risk assessment Overall, the global risk assessment has not changed, though the implication of the presence of the Asian lineage in Cabo Verde is yet unknown. Zika virus continues to spread geographically to areas where competent vectors are present. Although a decline in cases of Zika infection has been reported in some countries, or in some parts of countries, vigilance needs to remain high. At this stage, based on the evidence available, WHO does not see an overall decline in the outbreak.
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http://www.invs.sante.fr/Publications-et-outils/Points-epidemiologiques/Tous-les-numeros/Antilles-Guyane/2016/Situationepidemiologique-du-virus-Zika-aux-Antilles-Guyane.-Point-au-23-juin-2016 6 http://apps.who.int/ihr/eventinformation/announcement/32698-who-statement-third-meeting-international-health-regulations-2005ihr2005 7 http://apps.who.int/iris/bitstream/10665/207474/1/WHO_ZIKV_SRF_16.2_eng.pdf?ua=1 8 http://apps.who.int/iris/bitstream/10665/246091/1/WHO-ZIKV-SRF-16.3-eng.pdf?ua=1&ua=1 9 http://www.who.int/csr/resources/publications/zika/en/ 10 http://www.who.int/emergencies/zika-virus/en/ ; http://www.who.int/risk-communication/zika-virus/en/
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Figure 1. Cumulative number of countries, territories and areas by WHO region11 reporting mosquito-borne Zika virus transmission in years, 2007-2014, and monthly from 1 January 2015 to 29 June 2016
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http://www.who.int/about/regions/en/
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Table 1. Countries and territories reporting mosquito-borne Zika virus transmission Classification WHO Regional Office AFRO Country / territory / area Cabo Verde Anguilla, Argentina, Aruba, Barbados, Belize, Brazil, Bolivia (Plurinational State of), BONAIRE – Netherlands, Colombia, Costa Rica, Cuba, Curaçao, Dominica, Dominican Republic, Ecuador, El Salvador, French Guiana, Grenada, Guadeloupe, Guatemala, Guyana, Haiti, Honduras, Jamaica, Martinique, Mexico, Nicaragua, Panama, Paraguay, Peru§, Puerto Rico, Saint Barthelemy, Saint Lucia, Saint Martin, Saint Vincent and the Grenadines, Sint Maarten, Suriname, Trinidad & Tobago, United States Virgin Islands, Venezuela (Bolivarian Republic of) Maldives American Samoa, Fiji, Marshall Islands, Samoa, Tonga Gabon Bangladesh, Indonesia, Thailand Cambodia, Cook Islands, French Polynesia, Lao People’s Democratic Republic, Malaysia, Micronesia (Federated States of)*, New Caledonia, Papua New Guinea, Philippines, Solomon Islands, Vanuatu, Viet Nam ISLA DE PASCUA – Chile Total 1
Category 1. Countries and territories experiencing a first outbreak of Zika virus since AMRO/PAHO 2015, with no previous evidence of circulation, and with ongoing transmission by mosquitos. SEARO WPRO Subtotal AFRO Category 2. Countries and territories where there is SEARO evidence of Zika virus transmission from 2007 to 2014, with or without ongoing WPRO transmission; or countries where an outbreak since 2007 is reported to be over. PAHO Subtotal Total
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1 5 47 1 3
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1 17 64
Categories are defined as follows: Category 1. Countries experiencing a first outbreak of Zika virus, with no previous evidence of circulation, and with ongoing transmission by mosquitos: countries where Zika virus has recently been introduced, with no evidence of circulation in the past and where there is ongoing transmission. These countries present a high risk of Guillain-Barré syndrome, microcephaly and other neurological disorders associated with Zika virus. - Category 2. Countries where there is evidence of Zika virus transmission prior to 2015, with or without ongoing transmission or countries where the outbreak is reported to be over: this group includes countries that are not experiencing a first outbreak and where transmission has occurred at low levels in the past, and where transmission may or may not be ongoing or countries that have reported an outbreak since 2007 that is now over. This table lists countries that have experienced outbreaks after 2007, all countries with evidence of infection prior to 2007 are listed in http://www.who.int/bulletin/online_first/16-171082.pdf. *One island state (Yap) reported an outbreak in 2007
Table 2. Countries reporting non vector-borne Zika virus transmission Classification WHO Regional Office Country / territory / area Argentina, Canada, Chile, Peru, United States of America France, Germany, Italy, Portugal New Zealand Total 5 4 1 10 Countries with evidence of AMRO/PAHO person-to-person transmission of Zika virus, other than mosquito- EURO borne transmission WPRO Total
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Figure 2. Global spread of Zika virus, 2013-2016
ISLA DE PASCUA –Chile is not displayed in the map given the uncertainty in the start date. Circulation of Zika virus in Thailand, Cambodia an d Lao People’s Democratic Republic started before 2013. Countries where sexual transmission occurred are not represented in this map. Available information does not permit measurement of the risk of infection in any country; the variation in transmission intensity among countries is therefore NOT represented on this map. Zika virus is not necessarily present throughout the countries/territories shaded in this map
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Table 3. Countries, territories and areas reporting microcephaly and /or CNS malformation cases potentially associated with Zika virus infection Reporting country or territory Brazil Cabo Verde Colombia El Salvador French Guiana French Polynesia Marshall Islands Martinique Panama Puerto Rico Slovenia Spain United States of America* 16
Number of microcephaly and /or CNS malformation cases suggestive of Probable location of infection congenital infections or potentially associated with a Zika virus infection 1616 12
Brazil Cabo Verde Colombia El Salvador French Guiana French Polynesia Marshall Islands Martinique Panama Puerto Rico Brazil Colombia, Venezuela (Bolivarian Republic of) Undetermined**
6 13 11 1 1 8 1 14 6 5 1 15 1 2 8
* US-CDC has modified the way information is displayed. To protect the privacy of the women and children affected by Zika, US-CDC is not reporting individual state, tribal, territorial or jurisdictional level data. **The probable location of infection was Brazil (1 case) and Mexico, Belize or Guatemala (1 case). The probable location of infection for an additional case was Haiti.
Table 4. Countries, territories or areas reporting Guillain-Barré syndrome (GBS) potentially associated with Zika virus infection Classification Reported increase in incidence of GBS cases, with at least one GBS case with confirmed Zika virus infection No increase in GBS incidence reported, but at least one GBS case with confirmed Zika virus infection
Country / territory / area Brazil, Colombia, Dominican Republic, El Salvador*, French Guiana, French Polynesia, Honduras, Martinique, Suriname, Venezuela (Bolivarian Republic of) Guadeloupe , Haiti, Panama, Puerto Rico 17
*GBS cases with previous history of Zika virus infection were reported by the International Health Regulations (2005) National Focal Point in United States of America.
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http://portalsaude.saude.gov.br/index.php/cidadao/principal/agencia-saude/24202-ministerio-da-saude-confirma-1-616-casos-demicrocefalia-em-todo-o-pais 13 http://www.ins.gov.co/boletinepidemiologico/Boletn%20Epidemiolgico/2016%20Bolet%C3%ADn%20epidemiol%C3%B3gico%20semana%2024.pdf 14 http://www.invs.sante.fr/Publications-et-outils/Points-epidemiologiques/Tous-les-numeros/Antilles-Guyane/2016/Situationepidemiologique-du-virus-Zika-aux-Antilles-Guyane.-Point-au-23-juin-2016 15 http://www.nejm.org/doi/pdf/10.1056/NEJMoa1600651 16 http://www.cdc.gov/zika/geo/pregnancy-outcomes.html 17 http://www.invs.sante.fr/Publications-et-outils/Points-epidemiologiques/Tous-les-numeros/Antilles-Guyane/2016/Situationepidemiologique-du-virus-Zika-aux-Antilles-Guyane.-Point-au-23-juin-2016
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Table 5. Strategic Response Framework and Joint Operational Response Plan: summary of key response interventions Objectives Public health risk communication and community engagement activities Activities Coordinate and collaborate with partners on risk communication messaging and community engagement for Zika. Develop communication and knowledge packs and associated training on Zika virus and all related and evolving issues for communication experts. Engage communities to communicate risks associated with Zika virus disease and promote vector control, personal protection measures, reduce anxiety, address stigma, and dispel rumours and cultural misperceptions. Disseminate material on Zika and potentially associated complications for key audiences such as women of reproductive age, pregnant women, health workers, clinicians, and travel and transport sector stakeholders. Conduct social science research to understand perceptions, attitudes, expectations and behaviours regarding fertility decisions, contraception, abortion, pregnancy care and care of infants with microcephaly and persons with GBS. Support countries to monitor impact of risk communications. Regularly update and disseminate guidelines/recommendations on emergency Aedes spp. mosquito control and surveillance. Support insecticide resistance monitoring activities. Support countries in vector surveillance and control, including provision of equipment, insecticides, personal protection equipment (PPE) and training. Assess and support existing capacity and needs for health system strengthening, particularly around antenatal, birth and postnatal care, neurological and mental health services, and contraception and safe abortion. Map access barriers limiting women’s capacity to protect themselves against unintended pregnancy. Develop guidance for: families affected by microcephaly, GBS or other neurological conditions; women suspected or confirmed to have Zika virus infection, including women wanting to get pregnant, pregnant women and women who are breastfeeding; health workers on Zika virus health care, blood transfusion services, tools for triage of suspected Zika virus, chikungunya and dengue cases; and for health services management following a Zika virus outbreak. Provide technical support to countries on health service delivery refinements and national level planning to support anticipated increases in service needs. Procure and provide equipment and supplies to prepare their healthcare facilities in provision of specialized care for complications of Zika virus for prioritized countries and territories.
Vector control and personal protection against mosquitoes Care for those affected and advice for their caregivers
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