Zika virus, microcephaly and Guillain-Barré syndrome situation report

ZIKA VIRUS

SITUATION REPORT ZIKA VIRUS MICROCEPHALY GUILLAIN-BARRÉ SYNDROME 7 JULY 2016  WHO and partners have established a definition of what constitutes an outbreak, endemic transmission, and the interruption of vector-borne transmission in order to better characterize the level of transmission of Zika virus infection (Table 1, Fig. 2). In addition, this will facilitate public health recommendations for residents and travellers. Based on these definitions, countries and territories reporting mosquito-borne Zika virus transmission were reclassified.  As of 6 July 2016, 65 countries and territories (Fig. 1, Table 1) have reported evidence of vector-borne Zika virus transmission since 2007 (62 of these countries and territories have reported evidence of vector-borne Zika virus transmission since 2015):  48 countries and territories with a first reported outbreak from 2015 onwards (Table 1).  Four countries are classified as having possible endemic transmission or have reported evidence of local vector-borne Zika infections in 2016.  13 countries and territories have reported evidence of local vector-borne Zika infections in or before 2015, but without documentation of cases in 2016, or with outbreak terminated.  Guinea-Bissau is the latest country to report mosquito-borne Zika virus transmission.  Eleven countries have reported evidence of person-to-person transmission of Zika virus, probably via a sexual route (Table 2). Spain is the latest country to report Zika infection through person-to-person transmission.  As of 6 July 2016, microcephaly and other central nervous system (CNS) malformations potentially associated with Zika virus infection or suggestive of congenital infection have been reported by 13 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 6 July, the United States Centers for Disease Control and Prevention (US-CDC) reported seven live-born infants with birth defects and five pregnancy losses with birth defects with laboratory evidence of possible Zika virus infection.1  In the context of Zika virus circulation, 15 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). 1

https://www.cdc.gov/zika/geo/pregnancy-outcomes.html

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 Based on research to date, there is scientific consensus that Zika virus is a cause of microcephaly and GBS.  A case of GBS has recently been confirmed positive for Zika virus in Jamaica.  Zika virus infections were diagnosed in eight cases with severe neurologic conditions in Guadeloupe.2  A WHO mission to Guinea-Bissau will be conducted to assist in understanding the lineage of the Zika virus detected in the country using viral sequencing. The mission will also focus on the identification of priority activities to strengthen national response capacity.  The global Strategic Response Framework launched by WHO in February 2016 encompasses surveillance, response activities and research. An interim report3 describing some of the key activities being undertaken jointly by WHO and international, regional and national partners in response to this public health emergency was published on 27 May 2016. A revised strategy for the period of July 2016 to December 2017 was published on 17 June.4  WHO has developed new advice and information on diverse topics in the context of Zika virus.5 WHO’s latest information materials, news and resources to support corporate and programmatic risk communication and community engagement are available online.6 Risk assessment Overall, the global risk assessment has not changed. The implication of the presence of the Asian lineage of Zika virus in Cabo Verde is under investigation. 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, there is no 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-30-juin-2016 3 http://apps.who.int/iris/bitstream/10665/207474/1/WHO_ZIKV_SRF_16.2_eng.pdf?ua=1 4 http://apps.who.int/iris/bitstream/10665/246091/1/WHO-ZIKV-SRF-16.3-eng.pdf?ua=1&ua=1 5 http://www.who.int/csr/resources/publications/zika/en/ 6 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 region7 reporting mosquito-borne Zika virus transmission in years (2007–2014), and monthly from 1 January 2015 to 6 July 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, Guinea-Bissau Anguilla; Argentina; Aruba; Barbados; Belize; BONAIRE, SINT EUSTATIUS and SABA – Netherlands*; Bolivia (Plurinational State of); Brazil; 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 Barthélemy; Saint Lucia; Saint Martin; Saint Vincent and the Grenadines; Sint Maarten; Suriname; Trinidad & Tobago; United States Virgin Islands; Venezuela (Bolivarian Republic of) American Samoa; Fiji; Marshall Islands; Micronesia (Federated States of); Samoa; Tonga Total 2

Category 1: Countries with a first reported outbreak from 2015 onwards

AMRO/PAHO

40

WPRO

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Subtotal 48 Category 2: Countries SEARO Indonesia; Thailand 2 with possible endemic transmission or evidence Philippines; Viet Nam 2 of local vector-borne Zika WPRO infections in 2016 Subtotal 4 Category 3: Countries AFRO Gabon 1 with evidence of local PAHO/AMRO 1 ISLA DE PASCUA – Chile** vector-borne Zika infections in or before SEARO Bangladesh; Maldives 2 2015, but without Cambodia; Cook Islands**; French Polynesia**; Lao People’s documentation of cases in WPRO Democratic Republic; Malaysia; New Caledonia; Papua New Guinea; 9 2016, or outbreak Solomon Islands; Vanuatu terminated Subtotal 13 TOTAL 65 *This includes confirmed Zika virus cases reported in BONAIRE – Netherlands and SINT EUSTATIUS – Netherlands. **These countries and territories have not reported Zika virus cases in 2015 or 2016. Categories are defined as follows (Fig. 2): Category 1: Countries with a first reported outbreak from 2015 onwards  A laboratory confirmed, autochthonous, vector-borne case of Zika virus infection in an area where there is no evidence of circulation of the virus in the past (prior 2015), whether it is detected and reported by the country itself or by another state party diagnosing returning travellers OR  A laboratory confirmed, autochthonous, vector-borne case of Zika virus infection in an area where transmission has been previously interrupted. The assumption is that the size of the susceptible population has built up to a sufficient level to allow transmission again; the size of the outbreak will be a function of the size of the susceptible population OR  An increase of the incidence of laboratory confirmed, autochthonous, vector-borne Zika virus infection in areas where there is on-going transmission, above two standard deviations of the baseline rate, or doubling the number of cases over a 4-week period. Clusters of febrile illnesses, in particular when epidemiologically-linked to a confirmed case, should be microbiologically investigated. Category 2: Countries with possible endemic transmission or evidence of local vector-borne Zika infections in 2016 with the reporting period beginning in 2007  Countries or territories that have reported an outbreak with consistent presence of laboratory confirmed, autochthonous, vector-borne cases of Zika virus infection 12 months after the outbreak OR  Countries or territories where Zika virus has been circulating for several years with consistent presence of laboratory confirmed, autochthonous, vector-borne cases of Zika virus infection or evidence of local vector-borne Zika infections in 2016. Reports can be from the country or territory where infection occurred, or from a third party where the case is first recorded according to the International Health Regulations (IHR 2005). Countries with evidence of infection prior to 2007 are listed in http://www.who.int/bulletin/online_first/16-171082.pdf Category 3: Countries with evidence of local vector-borne Zika infections in or before 2015, but without documentation of cases in 2016, or outbreak terminated with the reporting period beginning in 2007  Absence of confirmed cases over a 3-month period in a specific geographical area with climatic conditions suitable for year-round arbovirus transmission, or over a 12-month period in an area with seasonal vector activity.

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Figure 2. Country categorization according to date of first report and date of last report of confirmed Zika virus

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, Spain New Zealand Total 5 5 1 11 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 3. Global spread of Zika virus, 2013-2016

ISLA DE PASCUA – Chile is not displayed in the map given uncertainty about the date of onset of the outbreak there. Circulation of Zika virus in Thailand, Cambodia and 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*

Number of microcephaly and /or CNS malformation cases suggestive of Probable location of infection congenital infections or potentially associated with a Zika virus infection 1638 6 9 13 1 1 8 1 10 6 5 1 11 1 2 12 12 8

Brazil Cabo Verde Colombia El Salvador French Guiana French Polynesia Marshall Islands Martinique Panama Puerto Rico Brazil Colombia, Venezuela (Bolivarian Republic of) Undetermined**

* 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), Haiti (1 case) and Mexico, Belize or Guatemala (1 case).

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, Jamaica, Martinique, Suriname, Venezuela (Bolivarian Republic of) Guadeloupe , Haiti, Panama, Puerto Rico 13

*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://combateaedes.saude.gov.br/images/pdf/informe_microcefalia_epidemiologico_32.pdf http://www.ins.gov.co/boletinepidemiologico/Boletn%20Epidemiolgico/2016%20Bolet%C3%ADn%20epidemiol%C3%B3gico%20semana%2025.pdf 1010 http://www.invs.sante.fr/fr/Publications-et-outils/Points-epidemiologiques/Tous-les-numeros/Antilles-Guyane/2016/Situationepidemiologique-du-virus-Zika-aux-Antilles-Guyane.-Point-au-23-juin-2016 11 http://www.nejm.org/doi/pdf/10.1056/NEJMoa1600651 12 http://www.cdc.gov/zika/geo/pregnancy-outcomes.html 13 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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