ZIKA VIRUS DISEASE AND ITS COMPLICATIONS SUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL ZIKA VIRUS DISEASE AND ITS COMPLICATIONS: SUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL George Santiago Dimech [email protected]Epidemiologist - DVM, MSc Bali, Indonesia on 17-18 November 2016 ROUNDTABLE MEETING ON ZIKA VIRUS: IMPROVING DETECTION, PREPAREDNESS, AND RESPONSE, THROUGH SURVEILLANCE AND RESEARCH
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ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
ZIKA VIRUS DISEASE AND ITS COMPLICATIONS:SUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
BACKGROUND (2015) – PERNAMBUCO - BRAZIL
• February / March: outbreak of an exanthematic disease without a diagnostic hypothesis
established, later (July) confirmed as Zika virus disease
• July: increase in the number of cases (from May) of Síndrome de Guillain-Barré (SGB)
• October 2015: increase (since August) in the prevalence of microcephaly
• It coincided temporarily with an epidemic of the Zika virus ~ 6-7 months earlier
• Subsequently, other congenital anomalies, placental insufficiency, fetal growth
retardation and fetal death associated with Zika virus infection during pregnancy were
described.
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
SITUATION REPORT – MYCROCEPHALY - PERNAMBUCO - BRAZIL
Pernambuco: 21,5% of reported cases and 18% of confirmedcases among the 27 states of Brazil.
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
Reported cases of dengue, chikungunya, zika and microcephaly (reported and confirmed) in the second epidemiological week. Pernambuco, 2015-2016
Source: Planilha de Acompanhamento Semanal Dengue (GCDFA/DGCDA), Sinan Online e CIEVS/SEVS/SES-PE
Outbreak of exanthematic disease of unknown etiology
Congenital syndrome associated with Zika virus infection
Triplice Epidemic: Zika, Dengue, Chikungunya
Zika Virus: 2015=~80.000 cases2016= 11.500 cases
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
Estimated cases of dengue, Zika, and reported cases of chikungunya and microcephaly (reported and confirmed) in the second epidemiological week. Pernambuco, 2015-2016
Source Planilha de Acompanhamento Semanal Dengue (GCDFA/DGCDA), Sinan Online e CIEVS/SEVS/SES-PE
Estimated cases of Zika: 81.000 reports*
Congenital syndrome associated with Zika virus infection
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
PERNAMBUCO: 185 cities distributed by 12 Health Regions
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
• ZIKA VIRUS DISEASE (ZIKV)
• GUILLAIN-BARRÉ SYNDROME (GBS) AND OTHER
NEUROLOGICAL COMPLICATIONS
• CONGENITAL SYNDROME ASSOCIATED WITH ZIKA VIRUS
INFECTION
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
• ZIKA VIRUS DISEASE (ZIKV)
• GUILLAIN-BARRÉ SYNDROME (GBS) AND OTHER
NEUROLOGICAL COMPLICATIONS
• CONGENITAL SYNDROME ASSOCIATED WITH ZIKA VIRUS
INFECTION
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
ZIKA VIRUS DISEASE (ZIKV) - BACKGROUND
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
ZIKA VIRUS DISEASE (ZIKV) - BACKGROUND
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
Zika virus (ZIKV)
• Transmission:
• Mosquitoes – Genus Aedes – More Important
• Others:
• Sexual
• man => woman / woman => man / man => man
• It seems more common than expected
• Confirmed elimination by semen for up to 6 months
• Pregnant women: Indication for use of condoms or sexual abstinece
• Vertical (mother-to-child): Malformations
• Blood transfusion
• Occupational (laboratorial accident)
Obs #1: Non confirmed means: urine, saliva.
Obs #2: Breast milk: particles were identified, but no evidence of transmission of the
• Full-term newborns for whom reliable information on gestational age at birth is
unavailable, it is recommended to use the standards from the WHO Multicentre
Growth
• http://www.who.int/childgrowth/standards/es/
2175
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
CLINICAL DESCRIPTION OF THE CONGENITAL SYNDROME ASSOCIATED WITH ZIKA (CSZ) VIRUS INFECTION**
• Presence of microcephaly:
• Pernambuco: 2.175 reports of (CSZ):
• 393 (18%) Confirmed (with congenital malformations especially of the central
nervous system, auditory, and visual that could be associated with ZIKV)
• 72 (18%) without microcephaly
• 1433 (66%) Discarded
• 351 (16%) Under investigation
2175
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
CLINICAL DESCRIPTION OF THE CONGENITAL SYNDROME ASSOCIATED WITH ZIKA VIRUS INFECTION
• Presence of microcephaly with other signs, such as:
• Facial or other disproportionality cranial-facial disproportion
• Anthropometric disproportions
• Redundant scalp with roughness
• Irritability: hypertonia/spasticity and epileptic / seizures -
• Joint disorders: artrogriposis
• Severe central nervous system compromise - presence of: cerebral calcifications
(mainly cortical and subcortical), cerebral ventricles, anomalies abnormalities of the
posterior fossa, and lissencephaly
• Auditory (hearing loss) and visual abnormalities
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
SÍNDROME CONGÊNITA ASSOCIADA AO ZIKA
SPECTRUM OF SYMPTOMS: (a) Axial transabdominal US performed at 36
weeks shows ventriculomegaly, calcifications in the thalamus and basal ganglia, and enlarged cisterna magna.
(b) Soft-tissue(c) Body bone reconstruction - The postnatal
bone reconstruction image showed the severe joint contractures, similar to those observed on (f)
(d) and (e) axial postmortem CT images show an abnormal profile, moderate ventriculomegaly, parenchymal atrophy, splaying of the cerebellar hemispheres, inferior vermianhypoplasia, and calcifications in the subcortical white matter, thalamus, and basal ganglia. The corpus callosum is not visualized. The gyral pattern is abnormally smooth for a term neonate.
(f) a photograph of the neonate.
SPECIAL REPORT: Congenital Brain Abnormalities and Zika Virus: What the Radiologist Can Expect to See Soares de Oliveira-Szejnfeld et al -Radiology: Volume 281: Number 2, 2016 n radiology.rsna.org
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
SÍNDROME CONGÊNITA ASSOCIADA AO ZIKA
BMJ 2016;354:i3899 | doi: 10.1136/bmj.i3899
Congenital Zika syndrome with arthrogryposis: retrospective - case series study. Vanessa van der Linden et al.
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
SÍNDROME CONGÊNITA ASSOCIADA AO ZIKA
Fundus Photographs of a 2-Month-Old Girl
The right eye has granular, pigmentary mottling in the macula (A), and the left eye has a chorioretinal lobulated atrophic lesion and slight pigmentary mottling (B).
OCULAR FINDINGS IN INFANTS WITH PRESUMED ZIKA VIRUS INFECTION
Fundus Photographs of a 1-Month-Old Boy
The right (A) and left (B) eyes have paramacular superotemporal round chorioretinal atrophy surrounded by a hyperpigmented halo and hyperpigmented mottling
Bruno de Paula Freitas et al JAMA Ophthalmology May 2016 Volume 134, Number 5
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
SÍNDROME CONGÊNITA ASSOCIADA AO ZIKA
OCULAR FINDINGS IN INFANTS WITH PRESUMED ZIKA VIRUS INFECTION
Bruno de Paula Freitas et al JAMA Ophthalmology May 2016 Volume 134, Number 5
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
SÍNDROME CONGÊNITA ASSOCIADA AO ZIKA
UPDATES THE CHARACTERIZATION OF ZIKA CONGENITAL SYNDROMEDigestive:• Gastroesophageal reflux (due to trunk-brain dysfunction);• Dysphagia and other severe deglutition and suctioning problems
• Some babies have a need for gastrostomy• Placing a feeding tube directly into the stomach, through the abdominal wall.
Others:• Hernias (umbilical / inguinal)• Change in genitalia (cryptorchidism / hypospadias• Hormonal disorders: the early pubic
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
SURVEILLANCE OF THE CONGENITAL SYNDROME ASSOCIATED WITH ZIKA VIRUS INFECTION – PRINCIPAL OBJECTIVES
• Establish the baseline and monitor the prevalence of births and trends of the congenital
syndrome associated with ZIKV infection, with microcephaly as a tracer event.
• Investigate any increase in the prevalence of microcephaly at birth or other associated
conditions.
• Detect and investigate all new cases of congenital malformations (including microcephaly)
not explained by other known causes.
• Detect the presence of infection in newborns of pregnant women who are receiving follow-
up due to detection of ZIKV.
SÍNDROME CONGÊNITA ASSOCIADA AO ZIKA
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
SURVEILLANCE OF THE CONGENITAL SYNDROME ASSOCIATED WITH ZIKA VIRUS INFECTION:
• Step #1 Design an ad hoc subsystem specifically for the detection of newborns with
congenital syndrome, and miscarriage, and fetal deaths
• Reports from sonographers, obstetricians, and maternal and child hospitals
• Step #2 Establish case definitions
• Step #3 Establish protocols
SÍNDROME CONGÊNITA ASSOCIADA AO ZIKA
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
SURVEILLANCE OF THE CONGENITAL SYNDROME ASSOCIATED WITH ZIKA VIRUS INFECTION – CASE DEFINITION
Suspected case of congenital syndrome associated with Zika virus infection: Live
newborn who presents with:
• Microcephaly: head circumference below -2 standard deviations measured at 24 hours
after birth according to the standardized guidelines for gestational age and sex; OR
• Other congenital malformation of the central nervous system;
AND whose mother during pregnancy:
• resided in or traveled to an area with the presence of ZIKV vectors; OR
• had unprotected sex with a partner who resided in, or traveled to, an area with the
presence of ZIKV vectors.
SÍNDROME CONGÊNITA ASSOCIADA AO ZIKA
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
SURVEILLANCE OF THE CONGENITAL SYNDROME ASSOCIATED WITH ZIKA VIRUS INFECTION – CASE DEFINITION
Probable case of congenital syndrome associated with Zika virus infection:
Live newborn who meets the criteria for a suspected case of congenital syndrome associated
with ZIKV AND
• who has intracranial morphological alterations diagnosed by any imaging method,
and excluding other known possible causes; OR
• whose mother had rash during pregnancy.
SÍNDROME CONGÊNITA ASSOCIADA AO ZIKA
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
SURVEILLANCE OF THE CONGENITAL SYNDROME ASSOCIATED WITH ZIKA VIRUS INFECTION – CASE DEFINITION
Confirmed case of congenital syndrome associated with Zika virus infection
• Live newborn of any gestational age who meets the criteria for a suspected case of
congenital syndrome associated with ZIKV, AND with laboratory confirmation of ZIKV
infection, independent of the detection of other agents.
SÍNDROME CONGÊNITA ASSOCIADA AO ZIKA
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
Summary of the recommendations for specifcally diagnosing Zika among newborns
Source: Falcao et al. Ann Clin Microbiol Antimicrob (2016) 15:57
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
SURVEILLANCE OF THE CONGENITAL SYNDROME ASSOCIATED WITH ZIKA VIRUS INFECTION – CASE DEFINITION
Suspected Zika-virus-associated abortion or stillbirth: Abortion or stillbirth in a woman, who during her pregnancy:• presented rash AND• resided in or travelled to an area where ZIKV vectors were present;• OR• had unprotected sex during pregnancy with a partner who resided in or travelled to an area
where ZIKV vectors were present.
Confirmed Zika-virus-associated abortion or stillbirth• All suspected cases where ZIKV infection is confirmed from blood or urine samples from
either the mother or puerperal or abortion or fetal death tissue.
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
• Families of neonates with congenital Zika virus syndrome should be informed about the diagnosis and advised regarding management and prognosis
• Psychosocial support and advice should be provided to families of neonates with congenital Zika virus syndrome
• Infants with congenital Zika syndrome should receive a comprehensive neurodevelopmentalassessment, and supportive therapy should be put in place for any difficulties notedincluding irritability, seizures, swallowing difficulties, early onset spasticity and hip dysplasia.
• Multidisciplinary approaches should be adopted to provide early interventions and support to promote neurodevelopment, prevent contractures and manage early complications
• Infants with congenital Zika virus syndrome should be followed up at 1 month, 3 months, 6 months, 9 months, 12 months, 18 months and 24 months of age. Additional follow-up should be provided if there are other complications. Further follow-up beyond 24 months of age will be required depending on the child’s condition and needs.
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
• At each visit, head circumference should be measured in order to monitor postnatal brain growth
• Developmental and neurological assessments should be performed with the full engagement of caregivers to identify developmental delays and other neurological abnormalities including epilepsy and disorders of movement, posture and swallowing.
• Hearing should be screened in the first month of life as early as possible before discharge from hospital and further audiological evaluation and services should be provided
• There should be comprehensive ophthalmological assessment.
• The health and well-being of the families and caregivers, including their psychological well-being should be assessed. Families and caregivers should be provided psychosocial support and parenting advice.
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
• Infants born to mothers with suspected, probable or confirmed Zika virus infection duringpregnancy, even without microcephaly or disproportionately small head relative to the faceor body, should be followed up to detect, manage and investigate signs ofneurodevelopmental abnormality including feeding difficulties, hearing or vision problem andpoor head growth. Follow-up visits should occur at 3 months, 9 months and 24 months of ageas a minimum.
ZIKA VIRUS DISEASE AND ITS COMPLICATIONSSUCCESSFUL EXPERIENCES AND CHALLENGES FOR SURVEILLANCE AND RESPONSE IN BRAZIL
Psychosocial support for pregnant women and for families with microcephaly and other
neurological complications in the context of Zika virus - Interim guidance for health-care providers