Zika Virus In

Pregnancy

Dr. Shashwat Jani.M. S. ( Obs – Gyn )

Diploma in Advance Laparoscopy.

Consultant Assistant Professor,

Smt. N.H.L. Municipal Medical College.Sheth V. S. General Hospital , Ahmedabad.

Mobile : +91 99099 44160.E-mail : drshashwatjani@gmail.com

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ZIKV- A member of the Flaviviridae virus family and the Flavivirus genus

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Zika Virus

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The virus was named after the region where it was found in the

Zika Forest of Uganda — in 1947

Why It Is Called As Zika ???

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History

Isolated Fist in 1947 from rhesus macaque in the ZikaForest of Uganda

1968 - isolated for the first time from humans inNigeria

Since then, it has remained mainly in Africa, with small and sporadic outbreaks in Asia. In 2007, a major epidemic was reported on the island of Yap (Micronesia), where nearly 75% of the population was infected.

October 2013 -French PolynesiaMay 2015 - BrazilSince October 2015, other countries and territories of theAmericas have reported the presence of the virus

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WHO warned the mosquito-borne virus was likely to spread to all countries in the Americas except for Canada and Chile.

Why the fuss now?

• Rapid spread since its first detection in May 2015 in Brazil to 22 other countries and other territories in the Americas

• Possible association with a significant rise in the number of babies born with microcephaly and neurological disorders

• “Global Emergency” by the WHO

Petersen E et.al. 2016 at http://wwwnc.cdc.gov/eid8/22/2017

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Modes of transmission

Bite from an infected mosquito Maternal-fetal

– Intrauterine– Perinatal

Sexual transmission from an infected person to his or her partners

Laboratory exposure Theoretical: blood transfusion, organ and

tissue transplant, fertility treatment, and breast feeding

Incubation and viremia Incubation period for Zika virus disease is 3–14 days.

Zika viremia ranges from a few days to 1 week.

Some infected pregnant women can have evidence of Zikavirus in their blood longer than expected.

Virus remains in semen longer than in blood.

Low-grade fever (between 37.8°C and 38.5°C)arthralgia, notably of small joints of hands andfeet, with possible swollen joints

Myalgia

Headache, retro-ocular headaches

Conjunctivitis

Cutaneous maculopapular rash

Post-infection asthenia which seems to befrequent

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What Are The Symptoms ?

About 1 in 5 people infected with Zika virus become ill (i.e., develop Zika).

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Clinical features: Zika virus compared to dengue and chikungunya

DIAGNOSES & TESTING FOR ZIKA

Differential diagnosis

– Dengue

– Chikungunya

– Leptospirosis

– Malaria

– Riskettsia

– Group A Streptococcus

– Rubella

– Measles

Based on typical clinical features, the differential diagnosis for Zika virus infection is broad. Considerations include

– Parvovirus

– Enterovirus

– Adenovirus

– Other alphaviruses (e.g., Mayaro, Ross River, Barmah Forest, O’nyong-nyong, and Sindbis viruses)

Serology cross-reactions with other flaviviruses

Zika virus serology (IgM) can be positive due to antibodies against related flaviviruses (e.g., dengue and yellow fever viruses).

As viremia decreases over a time, a negative rRT-PCR collected after symptom onset does not preclude Zika; in this case, serologic testing should be performed.

Neutralizing antibody testing may discriminate between cross-reacting antibodies in primary flavivirusinfections.

Difficult to distinguish infecting virus in people previously infected with or vaccinated against a related flavivirus

Diagnostic testing for Zika virus

During first two weeks after the start of illness, Zika virus infection can often be diagnosed by performing real-time reverse transcriptase polymerase chain reaction (rRT-PCR) on serum and urine.

Serology for IgM and neutralizing antibodies in serum collected up to 12 weeks after illness onset

Plaque reduction neutralization test (PRNT) for presence of virus-specific neutralizing antibodies in paired serum samples

Immunohistochemical (IHC) staining for viral antigens or RT-PCR on fixed tissues

Recommendations

CDC recommends Zika virus testing for – Symptomatic people who live in or recently

traveled to an area with active Zika transmission, and

– People who have had unprotected sex with someone confirmed to have Zika virus infection or who lives in or traveled to an area with active Zika transmission.

All pregnant women in the US should be assessed for possible Zika exposure at each prenatal care visit.

Recommendations continued…

Pregnant women with possible Zika exposure and signs or symptoms consistent with Zika virus disease should be tested based on time of evaluation relative to symptom onset in accordance with CDC guidance.

Pregnant women with ongoing risk of possible Zika virus exposure and who do not report symptoms of Zika virus disease should be tested in the first and second trimester of pregnancy in accordance with CDC guidance.

• Zika virus can pass from a pregnant woman to her fetus during pregnancy or around the time of birth.

• It is not known how often this happens.

How can Zika affect pregnancies?

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• Infection during pregnancy can cause damage to the brain, microcephaly, and congenital Zika syndrome

• Linked to other problems, such as miscarriage, stillbirth, and birth defects

• No evidence that past infection will affect future pregnancies once the virus has cleared the body

How can Zika affect pregnancies?

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• Congenital Zika syndrome– Distinct pattern of birth defects in fetuses and infants of women infected during

pregnancy

– Associated with 5 types of birth defects not seen or rarely seen with other infections during pregnancy

• Severe microcephaly (small head size) resulting in a partially collapsed skull

• Decreased brain tissue with brain damage

• Damage to the back of the eye with a specific pattern of scarring and increased pigment

• Limited range of joint motion, such as clubfoot

• Too much muscle tone restricting body movement soon after birth

How can Zika affect pregnancies?

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Those infected with Zika during pregnancy appear to beable to transmit the virus to their fetuses. In some cases,this may lead to microcephaly, a terrible congenitalcondition that's associated with a small head andincomplete brain development. Babies born withmicrocephaly have a limited life expectancy and poorbrain function.

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In 2015, Zika virus RNA was detected in the amniotic fluid of twofetuses, indicating that it crossed the placenta and could cause fetal

infection. On 20 January 2016, scientists from the state of Paraná,Brazil, detected genetic material of Zika virus in the placenta of awoman, who had undergone an abortion due to the fetus'microcephaly, which confirmed that the virus is able to pass theplacenta

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Guillain–Barre syndrome

GBS is a rare disorder where a person’s own immune system

damages the nerve cells, causing muscle weakness and sometimes,

paralysis. These symptoms can last a few weeks or several months.

While most people fully recover from GBS, some people have

permanent damage and in rare cases, people have died.

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During the Zika virus outbreak in French Polynesia with 8750

suspected cases, 74 patients presented with neurological

syndromes or autoimmune syndromes following an illness with

symptoms compatible with Zika virus infection in previous days. Of

these, 42 were diagnosed as Guillain – Barrésyndrome

In Brazil, 121 cases of neurological manifestations and Guillain–

Barré syndrome (GBS) were notified .

WHO currently talking about a rate of 2.3 cases of Guillain-Barre for every 1,000 patients with Zika

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• No vaccine or medications are available to prevent or treat Zika infections.

• Treat the symptoms: – Get plenty of rest– Drink fluids to prevent dehydration– Take medicines, such as acetaminophen or paracetamol, to

relieve fever and pain• If you have Zika, avoid mosquito bites for the first week of

your illness. – During the first week of infection, Zika virus can be found

in the blood and passed from an infected person to another mosquito through mosquito bites.

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Treatment

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At the time of delivery

• histopathologic examination of the placenta and umbilical cord,

• testing of frozen placental tissue and cord tissue for Zika virus RNA, and

• testing of cord serum

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Clinical Management of infants with confirmed or possible zika

infection

Infants with confirmed or possible Zika infection

Doctors have found problems among fetuses and infants infected with Zika virus before birth, including

– Microcephlay

– Miscarriage

– Stillbirth

– Absent or poorly developed brain structures

– Defects of the eye

– Hearing deficits

– Impaired growth

Evaluation for all infants with positive or inconclusive Zika virus test results

Physical examination, measurement of head circumference, and assessment of gestational age

Evaluation neurologic abnormalities, dysmorphic features, enlarged liver or spleen, and rash/other skin lesions

Cranial ultrasound

Opthalmologic evaluation before hospital discharge or within 1 month after birth

Evaluation of hearing by evoked otoacoustic emissions testing or auditory brainstem response testing before hospital discharge or within 1 month after birth

Consultation with appropriate specialist for any abnormal findings

Additional evaluation for infants who have microcephaly or other findings consistent with congenital Zika virus infection

Consultation with clinical geneticist or dysmorphologist and pediatric neurologist

Testing for other congenital infections; consider consultation with pediatric infectious disease specialist

Complete blood count, platelet count, and liver function and enzyme tests

Genetic or other teratogenic causes should be considered if additional anomalies are identified.

Long term follow up for infants with positive or inconclusive Zika virus test results

Additional hearing screen at 6 months of age and audiology follow up of abnormal newborn hearing screening

Continued evaluation of developmental characteristics and milestones, as well as head circumference, through 1st year of life

Consultation with appropriate medical specialists (e.g., pediatric neurology, developmental and behavioral pediatrics, physical and speech therapy) if any abnormalities are noted and as concerns arise

Mosquito Bite Protection

Mosquito bite protection

Wear long-sleeved shirts and long pants.

Stay and sleep in places with air conditioning and window and door screens to keep mosquitoes outside.

Take steps to control mosquitoes inside and outside your home.

Sleep under a mosquito bed net if you are overseas or outside and are not able to protect yourself from mosquito bites.

Mosquito bite protection

Use Environmental Protection Agency (EPA)- registered insect repellents with one of the following active ingredients: DEET, picaridin, IR3535, oil of lemon eucalyptus, or para-menthane-diol.

Always follow the product label instructions.

Do not spray repellent on the skin under clothing.

If you are also using sunscreen, apply sunscreen before applying insect repellent.

Mosquito bite protection Do not use insect repellent on babies

younger than 2 months old.

Do not use products containing oil of lemon eucalyptus or para-menthane-diol on children younger than 3 years old.

Dress children in clothing that covers arms and legs.

Cover crib, stroller, and baby carrier with mosquito netting.

Do not apply insect repellent onto a child’s hands, eyes, mouth, and cut or irritated skin.

– Adults: Spray insect repellent onto your hands and then apply to a child’s face.

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IVC

BiologicalSource

reduction

Health Education

Personal Protection

Chemical•Community•School education•TV•Mass media & social networks

Bed nets and repellents, Wear long sleeves

•Insect growth regulators•Adulticides•Larvicides

•Intermittent irrigation•Water level management•Land filling•Channelling•Draining

•Exotic natural enemies•Larvivorous fish•Microbial agents•GMO

Integrated vector control

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Some Countries Are Employing Genetically Modified Mosquitoes to Fight the Virus

Sterile male Aedes mosquitoes could reduce the population, CNN reported. Some worry that this could have an unknown effect on the environment.

A genetically modified

version can be used to

cut down the mosquito

population and reduce

the Zika risk.

Dr. Shashwat Jani +91 99099 44160.

PREVENTION

Preventing sexual transmission

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• Zika can be passed through sex from a person who has Zika to his or her sex partners.

– Sex includes vaginal, anal, and oral sex and the sharing of sex toys.

– Zika can be passed through sex before symptoms start, during, and after symptoms end.

– It can be passed even if the infected person does not have symptoms at the time or never develops symptoms.

• Zika virus can stay in semen longer than in vaginal fluids, urine, and blood.

About sexual transmission

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• Not having sex eliminates the risk of getting Zika from sex.

• Condoms can reduce the chance of getting Zika from sex.

– Includes male and female condoms.

– Condoms should be used from start to finish, every time during vaginal, anal, and oral sex and the sharing of sex toys.

http://www.cdc.gov/mmwr/volumes/65/wr/pdfs/mm6529e2.pdf

Protect your partner

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Protect your partner

• People with a partner who traveled to an area with

risk of Zika can use condoms or not have sex

» If the traveler is female: For at least 8 weeks after return,

or after start of symptoms or diagnosis

» If the traveler is male: For at least 6 months after return, or

after start of symptoms or diagnosis

• People living in an area with risk of Zika can use condoms or

not have sex.

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