1. INTRODUCTION:

Zika virus disease is an emerging viral disease transmitted through the bite of an infected Aedes mosquito. This is the same mosquito that is known to transmit infections like dengue and chikungunya. Zika virus was first identified in Uganda in 1947. Outbreaks of Zika virus disease have been recorded in Africa, the Americas, Asia and the Pacific.

During large outbreaks in French Polynesia and Brazil in 2013 and 2015 respectively, national health authorities reported potential neurological and auto-immune complications of Zika virus disease. Currently, World Health Organization has reported 22 countries and territories in Americas from where local transmission of Zika virus has been reported. Microcephaly in the new born and other neurological syndromes(Guillain Barre Syndrome) have been found temporally associated with Zika virus infection. However, there are a number of genetic and other causes for microcephaly and neurological syndromes like Guillain Barre Syndrome. Zika virus disease has the potential for further international spread given the wide geographical distribution of the mosquito vector, a lack of immunity among population in newly affected areas and the high volume of international travel.[1-3] As of now, the disease has not been reported in India. However, the mosquito that transmits Zika virus, namely Aedes aegypti , There is currently an ongoing outbreak of Zika virus infections in South and Central America and the Caribbean, and increasing evidence that infection in pregnancy may be associated with fetal microcephaly and other central nervous system abnormalities. Zika virus infection has also been linked with Guillain-Barre syndrome. Symptomatic Zika virus infection is typically mild and short-lived in most individuals, but particular attention is required for travel-associated risks in women who are pregnant or who are planning a pregnancy.[2-3]

This guidance summarises key advice for those working in primary care, since they may be consulted by patients, including pregnant women, who are travelling to or returning from countries that are part of this outbreak (that is, those countries with active Zika transmZika virus is a flavivirus, closely related to dengue. It is transmitted to humans primarily through the bite of certain infected Aedes species mosquitoes. Aedes aegypti mosquitoes are commonly found in tropical and sub-tropical regions around the world including north Queensland and some areas in central Queensland. Another similar mosquito, Aedes albopictus, also has the potential to transmit Zika virus, but in Australia is only found in the Torres Strait. These mosquito vectors typically breed in domestic water-holding containers; they are daytime biters and feed both indoors and outdoors near dwellings.

Outbreaks of Zika virus are currently of have previously been reported in tropical Africa, Southeast Asia, Americas) Zika is a viral infection that usually causes a mild illness that typically lasts between 2 to 7 days.80% of people who become infected by Zika virus have no symptoms. Zika virus is spread through the bite of a mosquito that is found in certain countries. Infection with Zika virus has been strongly linked with a serious birth condition called microcephaly. Microcephaly means a baby born with an unusually small head. In these cases, the baby’s brain may not have formed properly during pregnancy. Cases of a neurological illness (called Guillain Barre Syndrome) possibly caused by Zika virus infection are also being studied. A number of cases of person to person spread have been reported, through sex.[3-4]

What is Zika Fever? :

This is a mosquito-borne viral illness caused by the Zika virus (ZIKV) on Zika. Zika virus is a flavi virus transmitted by Aedes mosquitoes found in South America, Latin America and the Caribbean. Originally found only in Africa and Asia, the virus was first reported in the Western Hemisphere in 2015. Zika is from the same family of viruses as Dengue and West Nile Virus that are also transmitted by Aedes mosquitoes. Mosquito-borne transmission is overwhelmingly the dominant mechanism of Zika transmission. There have been reports, outside of Canada, of both sexual transmission and transmission of Zika virus through the blood supply.[2-4]

How do People get Zika?:

Zika is transmitted to people through the bite of an infected Aedes mosquito. This is the same mosquito that transmits dengue and chikungunya. Zika is an infectious disease caused by the Zika virus, which is transmitted to people by Aedes red eyes mosquitoes. Symptoms of Zika typically include fever, rash, joint pain, and Zika occurs in many tropical and sub-tropical areas of the world, particularly in Africa, Southeast Asia, and islands in the Pacific Ocean. Zika virus is transmitted by Aedes aegypti mosquitoes (also known as yellow fever mosquitoes) and by Aedes albopictus mosquitoes (also known as Asian tiger mosquitoes). These mosquitoes are not native to California. However, since 2011 they have been detected in an Aedes mosquito can only transmit Zika virus after it bites a person who has this virus in their blood. Thus far in California, Zika virus infections have been documented only in a few people who were infected while traveling outside the United States. Zika virus is not spread through casual contact such as touching or hugging an infected person.[4-5].

What happens when people get Zika virus infection?:

Most people (80%) who are exposed to Zika virus will not get sick. If they do get sick, symptoms start2-7 days after being bitten by an infected mosquito. Symptoms may include fever, rash, joint pain, and conjunctivitis (red eyes).Central and South America, and the Caribbean.[2-4]

1.1. GUILLAIN BARRE SYNDROME:

Guillain-Barre syndrome in its typical form is an acute illness of the nerves that produces a lower, bilateral, and symmetrical sensorimotor development deficit. In many cases there is a history of infection prior to the development of the Guillain-Barre syndrome. The annual incidence of GBS is estimated to be between 0.4 and 4.0 cases per 100,000 inhabitants per year. In North America and Europe GBS is more common in adults and increases steadily with age. Several studies indicate that men tend to be more affected than women.[6-7].

1.2. DISEASE BACKGROUND INFORMATION:

Zika virus is a mosquito-borne flavi virus transmitted primarily by Aedes aegypti. Aedes albopictus mosquitoes might also transmit the virus. Outbreaks of Zika virus disease have been reported previously in Africa, Asia, and islands in the Pacific.

In 2013 and 2014, Zika virus outbreaks were notified in several islands of the Pacific region:

French Polynesia reported an outbreak with 8 750 suspected cases of Zika virus infection, identified by the syndromic surveillance sentinel network of French Polynesia. There were 383 confirmed cases, and Zika virus disease may have been the cause of an estimated 32 000 patients presenting to healthcare facilities between October 2013 and April 2014Further spread to New Caledonia, the Cook Islands and later to Easter Island (Chile) has shown the propensity of this arbovirus to spread in the Pacific region, outside its usual geographical range in Africa and south-east Asia. The virus found on Easter Island was closely related to the virus identified during the French-Polynesian outbreak, and cases were reported until June 2014. In 2015, autochthonous cases of Zika virus infection have been reported from Samoa and Solomon Islands (310 cases from February to May), New Caledonia (January to early August), Fiji (August), and at least one confirmed case in Vanuatu. In 2015, Zika virus spread in.

Brazil:

Zika virus infections have been laboratory confirmed in 18 states in Brazil since February 2015. The following states and regions are affected: northeast (Bahia, Maranhao, Pernambuco, Rio Grande do Norte, Paraíba, Alagoas, Ceara and Piaui), north (Amazonas, Para, Rondonia, Roraima and Tocantins), midwest (Mato Grosso), southeast (Espirito Santo, Rio de Janeiro and Sao Paulo) and south (Parana), see Figure 1. The Brazilian National IHR Focal Point also reports that cases of rash illness without laboratory confirmation have been notified in the state of Sergipe. The samples were negative for dengue and chikungunya. Investigations in Sergipe by the Field Epidemiology Training Program are ongoing. In May 2015, autochthonous transmission of Zika virus was confirmed in the states of Bahia and Rio Grande do Norte.

The surveillance model for Zika virus in Brazil is based on a sentinel network. Laboratory confirmation is done by RT-PCR in order to confirm autochthonous circulation as there are no standardized specific serological tests for Zika virus IgM or IgG antibodies available (cross-reaction with other flaviviruses especially with dengue fever).In a study conducted by the Salvador Health Authorities, twelve health districts in Salvador City the third-largest city in Brazil reported 14 835 cases of exanthematous illness between 15 February and 25 June 2015, with a peak incidence in May and an overall attack rate of 5.5 cases/10 000 inhabitants. The authors suggest that the outbreak was caused by Zika virus because the number of confirmed dengue cases did not vary substantially during the period; only 58 cases were diagnosed as chikungunya, and confirmed Zika virus infections occurred at the same time in other cities within metropolitan Salvador. A phylogenetic analysis of serum samples from patients hospitalized in March at Santa Helena Hospital in Camaçari, Bahia, showed that the identified Zika virus sequences belonged to the Asian lineage and were 99% identical with one partial Zika virus envelope gene region from a Zika virus isolate from French Polynesia. According to preliminary estimates from the Brazilian ministry of health, between 440 000 to 1 300 000 cases of Zika virus infections may have occurred in 2015 in Brazilian states with laboratory confirmed autochthonous cases of Zika virus. As of 4 December 2015, the Brazilian ministry of health reported 9 300 suspected cases of chikungunya and approximately half a million probable 4Cases of degue to PAHO.

Colombia:

In September, the state of Bolivar reported nine confirmed autochthonous cases of Zika virus disease. As of week 47, Colombia has reported 578 confirmed and 3 700 suspected cases, from 26 of Colombia’s 36 territorial entities.

El Salvador:

On 24 November, the IHR National Focal Point of El Salvador notified three confirmed autochthonous cases of Zika virus infection. On 3 December, the media reported 240 cases across the country.

Guatemala:

On 1 December, the media, quoting authorities, reported 17 suspected cases of Zika virus infection, 14 of which were among hospital employees. Blood samples were collected and sent to the US CDC for analysis. So far, one of the samples has been reported as positive.

Mexico:

On 26 November, the Mexican ministry of health acknowledged three Zika virus cases, including two autochthonous cases reported from Nuevo Leon and Chiapas. The imported case had a recent travel history in Colombia.

Panama:

On 3 December, the local health authorities reported three autochthonous cases among residents of the district of Ailigandi, in the north-eastern province of Guna Yala.

Paraguay:

On 27 November, Paraguay reported the confirmation of six Zika virus cases in the city of Pedro Juan Caballero, which borders Brazil, after an increase in the number of notified fever cases.

Venezuela:

On 27 November, the Venezuelan IHR National Focal Point notified seven Zika virus cases (autochthonous transmission is suspected), four of which were confirmed by RT-PCR. On 3 November 2015.

Cape Verdean:

Ministry of health reported that 17 out of 64 blood samples sent for confirmation to Pasteur Institute in Dakar were positive for Zika virus. According to the ministry, approximately 1 000 suspected cases with symptoms consistent with Zika virus infection were recorded as of 1 November 2015 [43].The overall distribution is reported in Figure 2 below (as of 4 December).

1.3. RELATIONSHIP BETWEEN ZIKA VIRUS AND MICROCEPHALY IN NEWBORNS:

What’s the relationship between Zika virus and microcephaly in newborns?:

There is a possible association between Zika and abnormally small head and brain in newborns. It is suspected that women who get infected with Zika virus may pass the virus to the developing fetus if they are pregnant. However, there are many causes of microcephaly in babies, and whether Zika virus infection causes microcephaly has not been confirmed. Studies are needed to understand this possible relationship.[9-10]

1.4. GENS OF ZIKA VIRUS:

Genus Flavivirus, Family Flaviviridae Closely related to dengue, yellow fever, Japanese encephalitis and West Nile viruses Transmitted to humans primarily Aedes (Stegomyia) species mosquit Aedesaegypti and Aedesalbopictus Mosquitoes : Geoghic Dis tribution in the united states aedesaegypti.[14-16]

Figure 3. Gens of Zika Virus Geoghic Distribution in the united states.

2. SIGNS AND SYMPTOMS:

The incubation period (the time from exposure to symptoms) of Zika virus disease is not clear, but is likely to be a few days. The symptoms are similar to other arbovirus infections such as dengue, and include fever, skin rashes, conjunctivitis, muscle and joint pain, malaise, and headache. These symptoms are usually mild and last for 2-7 days. Only one out of four infected people develops symptoms of the disease. Zika virus infection should be suspected in patients reporting with acute onset of fever, maculo-papular rash and arthralgia, among those individuals who travelled to areas with ongoing transmission during the two weeks preceding the onset of illness. Based on the available information of previous outbreaks, severe forms of disease requiring hospitalization is uncommon and fatalities are rare. Recently in Brazil, local health authorities have observed an increase in Zika virus infections in the general public as well as an increase in babies born with microcephaly in northeast Brazil. Agencies investigating the Zika outbreaks are finding an increasing body of evidence about the link between Zika virus and microcephaly. However, more investigation is needed before we understand the relationship between microcephaly in babies and the Zika virus. Other potential causes are also being investigated. An estimated three out of four people infected with Zika virus do not have symptoms at all. For those who have symptoms, Zika virus generally causes a mild illness that lasts for 2to7 days. The time between being infected by a mosquito bite and developing symptoms is usually between 3 and 12 days. Elderly people and those with weakened immune systems e.g. people living with cancer, may have more severe symptoms, but full recovery is usually the rule. The most symptoms Zike Fever are:

· Rash (whichmayitch),

· Redness of eyes ,

· Joint pains ,

· Headache ,

· Myalgia (muscle pain) ,

· Oedema (swelling) in lower limbs,

· Myalgia (muscle pain) ,

· Weakness etc.

Persons may also experience:

· Vomiting ,

· Diarrhoea ,

· Loss of appetite ,

· Abdominal pain.

Birth defects have been seen in some newborns whose mothers had Zika Fever (Zika Virus Infection) in pregnancy. There are neurological (brain and nerve related) and autoimmune complications that have been noted as well.[16-18].

2.1. CLINICAL DISEASE:

About one in five people infected with Zika virus become symptomatic. Characteristic clinical finding include acute onset of fever, maculopapular rash, arthralgia, or conjunctivitis. Clinical illness usually is mild with symptoms lasting for several days to a week. Severe disease requiring hospitalization is uncommon and fatalities are rare. During the current outbreak in Brazil, Zika virus RNA has been identified in tissues from several infants with microcephaly and from fetal losses in women infected during pregnancy. The Brazil Ministry of Health has reported a marked increase in the number of babies born with microcephaly. However, it is not known how many of the microcephaly cases are associated with Zika virus infection and what factors increase risk to the fetus. Guillain-Barre syndrome also has been reported in 2 patients following suspected Zika virus infection.[20-21].

2.2. CAUSATIVE AGENT:

Zika virus disease is caused by Zika virus which belongs to the genre Flavivirus. this viruse is transmitted by the bite from an infected mosquito hence a so called arboviruses. The reservoir of infectionl is not known.[22-24]

3. TRANSMISSION:

Zika virus is transmitted to people through the bite of an infected mosquito from the Aedes genus, mainly Aedes aegypti, which usually bite during the morning and late afternoon hours. Transmission from a infected pregnant mother to her baby during pregnancy or around the time birth is also being seen as a distinct possibility.[25-27] .

Zika virus is spread when an infected mosquito bites a person:

Other less common possible forms of transmission include:

· From mother to baby during pregnancy or childbirth.

· From an infected partner during unprotected sex (without a condom).

· From a blood transfusion.

Zika virus is not spread by the following:

· Regular social contact.

· Usage of communal household utensils.

· Caring for someone with Zika virus.

Zika virus is spread to people through the bite of an infected mosquito. It can also transmitted from apregnant mother who has been bitten by an infected mosquito to her baby during pregnancy or around the time of birth. Outbreaks of Zika have occurred in areas of Africa, Southeast Asia, and the Pacific Islands. During 2015,Zika virus was found in South America for the first time. Since then, it has spread to many countries.

How is Zika spread from mother to baby?:

It is currently thought that Zika virus may be transmitted from mother to baby from their shared blood supply during pregnancy. Zika spread through sexual contact, Zika virus can be passed between sexual partners in the man’s semen. This is more likely if the manhad symptoms of Zika virus infection. For this reason, it is important to practice safe sex (by wearinga condom) with a partner who has recently returned from, or is living in, an affected area.

Recommendations for Pregnant Women Considering Travel to a Area Zika Virus Transmission:

Because there is neither a vaccine nor prophylactic medications available to prevent Zika virus infection, CDC recommends that all pregnant women consider postponing travel to areas where Zika virus transmission is ongoing. If a pregnant woman travels to an area with Zika virus transmission, she should be advised to strictly follow steps to avoid mosquito bites. Mosquitoes that spread Zika virus bite both indoors and outdoors, mostly during the daytime; therefore, it is important to ensure protection from mosquitoes throughout the entire day. Mosquito prevention strategies include wearing long-sleeved shirts and long pants, using U.S. Environmental Protection Agency (EPA)–registered insect repellents, using permethrin-treated clothing and gear, and staying and sleeping in screened-in or air-conditioned rooms. When used as directed on the product label, insect repellents containing DEET, picaridin, and IR3535 are safe for pregnant women.

Recommendations for Pregnant Women with History of Travel to an Area of Zika Virus Transmission:

Health care providers should ask all pregnant women about recent travel. Women who traveled to an area with ongoing Zika virus transmission during pregnancy should be evaluated for Zika virus infection and tested in accordance with CDC Interim Guidance (Figure). Because of the similar geographic distribution and clinical presentation of Zika, dengue, and chikungunya virus infection, patients with symptoms consistent with Zika virus disease should also be evaluated for dengue and chikungunya virus infection, in accordance with existing guidelines. Zika virus testing of maternal serum includes reverse transcription-polymerase chain reaction (RT-PCR) testing for symptomatic patients with onset of symptoms within the Pregnant woman with history of travel to an area with Zika virus transmission Pregnant woman reports clinical illness consistent with Zika virus disease during or within 2 weeks of travel Test for Zika virus infection Positive or inconclusive test for Zika virus infection Fetal ultrasound to detect microcephaly or intracranial calci cations amniocentesis for Zika virus testing Negative test(s) for Zika virus infection Fetal ultrasound to detect microcephaly Consider amniocentesis for Zika virus testing Pregnant woman does NOT report clinical illness consistent with Zika virus disease during or within 2 weeks of travel Fetal ultrasound to detect microcephaly present Test pregnant woman for Zika virus infection Consider amniocentesis for Zika virus testing Consider serial ultrasounds to detect development of microcephaly Immunoglobulin M (IgM) and neutralizing antibody testing should be performed on specimens collected 4 days after onset of symptoms. Cross-reaction with related flaviviruses (e.g., dengue or yellow fever) is common with antibody testing, and thus it might be difficult to distinguish Zika virus infection from other flavivirus infections. Consultation with state or local health departments might be necessary to assist with interpretation of results . Testing of asymptomatic pregnant women is not recommended in the absence of fetal microcephaly or intracranial calcifications.

Zika Virus: Countries and Territories with Active Zika Virus Transmission:

Preventing potential sexual transmission of Zika virus .The risk of sexual transmission of Zika virus is thought to be very low, but male-to-female sexual transmission has been reported. If a female partner is at risk of getting pregnant, or is already pregnant, condom use is advised for a male partner arriving from an affected area for the following durations:

· 28 days after his return from an area with active Zika virus transmission if he has not had any symptoms compatible with Zika virus infection .

· Six months following recovery if a clinical illness compatible with Zika virus infection or laboratory-confirmed Zika virus infection was reported.

· The remaining duration of pregnancy if he is the partner of a pregnant woman, regardless of a history of symptoms suggestive of Zika virus infection .This is a precautionary approach and may be revised as more information becomes available. Twenty-eight days represents an estimated 14 day incubation period plus an estimated 14 day period of viraemia.

· Zika virus RNA has been detected in semen at 62 days following onset of typical acute Zika virus illness in a single case. The suggested six month period of condom use for men who had suspected or confirmed Zika virus infection reflects a precautionary approach whilst further evidence is gathered.

Fig.4 Zika Virus: Countries and Territories with Active Zika Virus Transmission

· Recommendations for women planning pregnancy who have travelled to or arrived from an area with active Zika virus transmission After a woman leaves an area with active Zika virus transmission.

· It is recommended that she should avoid becoming pregnant for 28 days (this covers an estimated 14 day incubation period plus an estimated 14 day period).

3.1. Sexual Transmission:

Given the current uncertainty and the potentially serious implications of sexual transmission of the virus to a pregnant woman, recommendations to reduce the risk have been developed. Further details can be found at Interim recommendations for reducing the risk of sexual transmission of Zika virus. Men who have travelled to an area with ongoing Zika virus transmission, whose partner is pregnant should abstain from sexual activity (vaginal, anal, or oral) or consistently use condoms for the duration of the pregnancy, whether symptomatic or asymptomatic. Men who have had a confirmed Zika virus infection, whose partner is not pregnant should abstain from sexual activity (vaginal, anal, or oral) consistently use condoms for 3 months solution .This cautious advice is directed toward the population of most concern pregnant women and those planning pregnancy; however partners of men with a confirmed Zika virus infection would also be protected from potential sexual transmission by this advice. This is of most relevance to people in North Queensland where the vector is present and the potential for further spred.

3.2. Blood Transfusion:

Case Deferral A person diagnosed with Zika virus infection should be advised that they cannot donate blood for a minimum of 4 weeks after recovery of all symptoms. Sexual Contact Deferral A sexual contact of a person diagnosed with Zika virus infection should be advised that donation is not possible for four weeks after sexual contact with someone who;

· Has current Zika virus infection, or

· Has recovered from Zika virus infection in the preceding three months.

4. WHAT IS MICROCEPHALY?:

Clinical finding of a small head when compared to infants of same sex and age Measured by head circumference (HC) or (OFC) primary due to abnormal development (often with a genetic etiology) secondary due to arrest or destruction of normally-forming brain tissue (by infection, vascular disruption) Difficult birth defect to monitor because of inconsistent definition. Microcephaly is an uncommon condition where a baby’s head circumference is less than expected based on the average for their age and sex. The condition is usually a result of the failure of the brain to develop properly, and can be caused by genetic or environmental factors such as exposure to toxicins, radiation, or infection during development in the womb. Microcephaly can be present as an isolated condition or may be associated with other symptoms.[6-8]

Fig 5. Microcephaly with baby head size.

5. EPIDEMIOLOGY:

ZIKA was first discovered in a Rhesus monkey in Uganda in 1947 and in humans a few years later, yet few outbreaks have been documented. The first ZIKV outbreak reported outside of Africa and Asia occurred in Micronesia in 2007.This was followed by an outbreak of the same strain in French Polynesia in 2013; since then there have been major outbreaks in other parts of the Pacific. Brazil reported its first case of local transmission of ZIKA in May 2015.Since then the virus has spread rapidly; as of 27 January 2016, ZIKV transmission is occurring in 23 countries and territories in South/Central America and the Caribbean, as well as in countries outside this region.[22-24. The list of countries with active ZIKV transmission will be updated weekly As of 29 January 2016, countries currently experiencing active transmission are: Barbados, Bolivia, Brazil, Cape 2 Verde, Colombia, Dominican Republic, Ecuador, El Salvador, French Guiana, Guadeloupe, Guatemala, Guyana, Haiti, Honduras, Martinique, Mexico, Nicaragua, Panama, Paraguay, Puerto Rico, Saint Martin, Samoa, Suriname, Thailand, Venezuela, US Virgin Islands. This rapid spread over the past few months is mainly due to two factors:

1. The population in this part of the world had not previously been exposed to ZIKV lacked immunity.

2. Aedes mosquitoes, the main vector for ZIKV transmission, are present in all of these regions/countries in the Americas, apart from Canada and continental Chile. It is likely that this rapid spread of ZIKV will continue until it reaches all countries of the region where the Aedes mosquito.

6. DIAGNOSIS:

Zika virus Is diagnosed through PCR (polymerase chain reaction) and virus isolation from blood samples. Diagnosis by serology is not recommended. Zika virus infection can be diagnosed in a patient who has Zika symptoms and a relevant travel history to an affected area. Laboratory tests are currently available for blood and urine for symptomatic patients recently returned from an affected area. Zika virus infection should be considered in patients with acute onset of fever, maculopapular rash, arthralgia, conjunctivitis who recently returned from affected areas. To confirm evidence of Zika virus infection, RT-PCR should be performed on serum, Immunoglobulin M and neutralizing antibody testing should be performed on specimens collected 4 days after onset of illness. Zika virus IgM antibody assays can be positive due to antibodies against related flaviviruses (e.g., dengue and yellow fever viruses). Virus-specific neutralization testing provides added specificity but might not discriminate between cross-reacting antibodies in people who have been previously infected with or vaccinated against a related flavivirus. There is no commercially available test for Zika virus. Zika virus testing is performed at the CDC Arbovirus Diagnostic Laboratory and a few state health departments. CDC is working to expand laboratory diagnostic testing in states, using existing RT-PCR protocols. Healthcare providers should contact their state or local health department. The diagnosis of ZIKV infection should be considered among individuals returning from South or Central America, the Caribbean, or the Pacific region who developed a fever and/or other symptoms suggestive of ZIKV while abroad or within two weeks returning to the UK. Healthcare providers should ask all pregnant women about recent and planned travel. The mainstay of testing for ZIKV in maternal serum is reverse transcription polymerase chain reaction (RT-PCR) for symptomatic patients with onset of symptoms within the previous week. Antibody testing is less reliable due to potential cross-reaction with antibodies against other similar viruses (e.g. dengue or yellow fever, which are often co-located), making it difficult to differentiate ZIKV infection using antibody testing alone. ZIKV RT-PCR can also be performed on amniotic fluid13,16 although it is currently not known how sensitive or specific this test is for congenital infection, or the likelihood of an infected fetus being affected, i.e. subsequently developing a fetal abnormality. The symptoms of Zika are similar to those of dengue and chikungunya, which are diseases caused by other viruses spread by the same type of mosquitoes. See your healthcare provider if you develop the symptoms described above and have visited an area where Zika is present. If you are at risk, your healthcare provider may order blood tests to look for Zika or other similar viruses. Based on the typical clinical features, the differential diagnosis for Zika virus infection is broad. In addition to dengue, other considerations include leptospirosis, malaria, Rickettsia, group A Streptococcus, rubella, measles, and Parvovirus, Enterovirus, Adenovirus, and Alphavirus infections (e.g., Chikungunya, Mayaro, Ross River, Barmah Forest, O’ nyong-nyong, and Sindbis viruses). Preliminary diagnosis is based on the patient’s clinical features, places and dates of travel, and activities. Laboratory diagnosis is generally accomplished by testing serum or plasma to detect virus, viral nucleic acid, or virus-specific immunoglobulin M and neutralizing antibodies.[28-30].

How to Treat Pregnant Women with Diagnoses of Zika Virus Disease :

No specific antiviral treatment is available for Zika virus disease. Treatment is generally supportive and can include rest, fluids, and use of analgesics and antipyretics. Fever should be treated with acetaminophen. Although aspirin and other non-steroidal anti-inflammatory drugs are not typically used in pregnancy, these medications should specifically be avoided until dengue can be ruled out to reduce the risk for hemorrhage. In pregnant a woman with laboratory evidence of Zika virus in serum or amniotic fluid, serial ultrasounds should be considered to monitor fetal anatomy and growth every 3–4 weeks. Referral to a maternal-fetal medicine or infectious disease specialist with expertise in pregnancy management is recommended.

6.1. LABORATORY SAFETY:

Zika and dengue viruses are classified as biological safety level (BSL) 2 pathogens while chikungunya virus is classified as a BSL-3 agent. All should be handled in accordance with Biosafety in Microbiological and Biomedical Laboratories (BMBL) guidelines and a risk assessment performed for each laboratory for the specific procedures utilized. Until the association between Zika virus infection and congenital microcephaly is better understood, pregnancy should be considered a significant factor in risk assessment for individuals working with Zika virus, and the involvement of pregnant workers in studies with Zika virus should be minimized. It is recommended that laboratories perform a risk assessment when bringing on new tests, and safety precautions should be based on each laboratory’s risk assessment. In particular, because chikungunya virus produces such high levels of viremia, serum from suspected chikungunya virus cases should be treated as potentially infectious even for serological procedures. For further information.[29-32].

6.2. Reporting:

Zika, dengue, and chikungunya are all nationally notifiable conditions; state and territory health departments should report cases to CDC according to standard CSTE case definitions. State and territory health departments are requested to report laboratory-confirmed cases of any arbovirus to CDC through ArboNET, the national surveillance system for arboviral disease.[33-34]

7. TREATMENT:

7.1. Is there any treatment for Zika virus?:

There is no specific treatment for Zika virus infections, but most people do not become seriously ill and recover quickly. If you are pregnant and are bitten by mosquitoes while traveling in an area with Zikavirus, you should contact your prenatal care provider. Specific testing for Zika virus is limited, and not always necessary. However your healthcare provider may suggest using ultrasound to check on the baby. Transmission of Zika virus is through the bite of an infected mosquito, most commonly Aedes aegypti. There are no reports at this time of infants becoming infected through breastfeeding. Zika virus disease is usually relatively mild and requires no specific treatment. People sick with Zika virus should get plenty of rest, drink enough fluids, and treat pain and fever with paracetamol. If symptoms worsen, they should seek medical care and advice. There is currently no vaccine available. There is no specific medication for the treatment of Zika Fever (Zika Virus Infection). Medication can be taken to reduce the fever, pain and other symptoms. However, only Paracetamol (Acetaminophen) should be used for pain and fever. DO NOT TAKE pain killers such as aspirin, ibuprofen and other anti-inflammatory drugs e.g. diclofenac. Check with your Doctor or Pharmacist to be sure! No specific antiviral treatment is available for Zika virus disease. Treatment is generally supportive and can include rest, fluids, and use of analgesics and antipyretics. Because of similar geographic distribution and symptoms, patients with suspected Zika virus infections also should be evaluated and managed for possible dengue or chikungunya virus infection. Aspirin and other non-steroidal anti-inflammatory drugs(NSAIDs) should be avoided until dengue can be ruled out to reduce the risk of hemorrhage. In particular, pregnant women who have a fever should be treated with acetaminophen. People infected with Zika, chikungunya, or dengue virus should be protected from further mosquito exposure during the first few days of illness to reduce the risk of local transmission.[30-34.

7.2. Is there a treatment for Zika during pregnancy?:

There is no vaccine or specific treatment for Zika virus infection. Treatment for everyone, including pregnant women, is by relieving pain, fever and any other symptoms. To prevent dehydration, it is advised to control the fever, rest and drink plenty of water. In the UK, the National Travel Health Network and Centre (NaTHNaC) now advises that pregnant women should consider avoiding travel to countries where ZIKV outbreaks are ongoing, in order to reduce the risk to their babies An ongoing outbreak is defined as active ZIKV transmission, i.e. locally acquired cases reported in the last 6 months. Health Protection Scotland give similar advice to carefully consider travel plans in view of the ZIKV risk, via TRAVAX and Fit for Travel Pregnant women who must travel (or choose to travel) to a country with an ongoing ZIKV outbreak should take all necessary precautions to minimize the chances of a mosquito bite, as described above. Pregnant women recently returned to the UK from countries with an ongoing outbreak of ZIKV should inform their obstetrician, midwife or GP that they may have been exposed to the Zika virus so that they can be monitored and/or tested. In the United States, the Centers for Disease Control and Prevention (CDC) now recommends that all pregnant women should consider postponing travel to areas where ZIKV transmission is ongoing;22 a number of other countries have issued similar advice. The WHO has stopped short of recommending that pregnant women should postpone travel to these countries.

7.3. General travel advice for patients:

Those working in primary care may be consulted by patients travelling to or returning from areas with active Zika virus transmission. Pregnant women may also request letters to justify suspension of travel to affected areas on medical grounds. In such cases, those working in primary care can refer to updated National Travel Health Network and Centre (NaTHNaC) advice, which has been produced in response to the ongoing Zika outbreak in South and Central America and the Caribbean. It is recommended that pregnant women, planning to travel should postpone non-essential travel to areas with active Zika virus transmission until after pregnancy. In addition it is recommended that women should avoid becoming pregnant while travelling in an area with active Zika virus transmission, and for 28 days after their return. In the event that travel to an area with active Zika virus transmission cannot be postponed, the pregnant traveler or those planning pregnancy must be informed by the healthcare provider of the risks which Zika may present. All pregnant women who have recently travelled to a country where active Zika transmission is reported should notify their primary care clinician, obstetrician or midwife. All travellers to areas with active Zika virus transmission should practice mosquito bite avoidance measures, both during daytime and night time hours (but especially during mid-morning and late afternoon to dusk, when the mosquito that transmits Zika virus is most active). An application of insect repellent containing 50% DEET (N,N-diethyl-m-toluamide) will repel mosquitoes for approximately 12 hours. Repellents containing up to 50% DEET can be used by pregnant women, but higher concentrations should not be used. When both sunscreen and DEET are required, DEET should be applied after the sunscreen. Sunscreen with a 30 to 50 SPF rating should be applied to compensate for DEET-induced reduction in SPF. The use of DEET is not recommended for infants less than two months of age. [31-35.

8. PREVENTION:

There is currently no vaccine or drug available to prevent ZIKV infection. The Aedes mosquito, the main vector for ZIKV, is active predominantly during daylight hours; bites are most common during mid-morning and late afternoon to dusk, when the mosquito is most active. This is in contrast to the Anopheles mosquito which transmits malaria and which is more active by night. Travellers to countries with ongoing outbreaks of ZIKV should take all possible measures to minimize the chances of mosquito bites. This includes wearing light-coloured, loose-fitting clothes that cover as much exposed skin as possible, for example long trousers and long sleeves. N, N-diethyl meta toluamide (DEET) based repellents are the most effective insect repellents widely available, and have been in use for over 50 years. Preparations with concentrations of DEET up to 50% are commonly available and are safe in pregnant and breastfeeding women (and in infants and children over the age of 2 months). Care should be taken to ensure that insect repellents are not ingested, and that they do not come in contact with the eyes or mouth. Insect repellents should be re-applied regularly, particularly after swimming and in hot humid conditions when they may be removed by perspiration. When both sunscreen and insect repellents are required, the insect repellent should be applied over the sunscreen. DEET based repellents can reduce the sun protection factor (SPF) of sunscreen so pregnant women should consider wearing a higher factor sun cream (SPF 30-50) when also using DEET based repellents. The following are not recommended as insect repellents: Citronella Oil based repellents (these have a very short duration of action), vitamin B12 complex, vitamin B1, tea tree oil Travelers staying in accommodation without screening should sleep under a mosquito net, particularly in malaria risk areas. Those sleeping during the day in an area with ZIKV should sleep under a mosquito net (if sleeping in accommodation without screening). Ideally, nets should be impregnated with permethrin or another contact insecticide. Retreatment after six months of use is necessary.[33-36].

8.1. Help Control Mosquitoes that Spread Dengue, Chikungunya, and Zika Viruses:

A side from being itchy and annoying, the bite of an infected female mosquito (Aedes aegypti or Aedes albopictus) can spread dengue, chikungunya, or Zika viruses. People become infected with dengue, chikungunya, or Zika after being bitten by an infected mosquito. Female mosquitoes lay several hundred eggs on the walls of water-filled containers. Eggs stick to containers like glue and remain attached until they are Adult mosquitoes live inside [34-37]

Fig 6. Put plants in soil, not in water.

Fig 7. Drain water from pools when not in use.

8.2. Protect Yourself, Your Family, and Community from Mosquitoes Eliminate standing water in and around your home:

Once a week, empty and scrub, turn over, cover, or throw out items that hold water, such as tires, buckets, planters, toys, pools, birdbaths, flowerpots, or trash containers. Check inside and outside your home. Tightly cover water storage containers (buckets, cisterns, rain barrels) so that mosquitoes cannot get inside to lay eggs. For containers without lids, use wire mesh smaller than an adult mosquito. If you have a septic tank, follow these steps: Repair cracks or gaps. Cover open vent or plumbing pipes. Use wire mesh with holes smaller than an adult mosquito.

Fig 8. Weekly, scrub vases and containers remove mosquito eggs.

8.3. Mosquito Bite Prevention for Travelers:

Mosquitoes spread many types of viruses and parasites that can cause diseases like chikungunya, dengue, Zika, and malaria. If you are traveling to an area where malaria is found, talk to your healthcare provider about malaria prevention medication that may be available.[33-34].

8.4. Your Best Protection: Prevent Mosquito Bites Clothing:

Wear long-sleeved shirts and long pants. Treat clothing and gear with permethrin or purchase permethrin-treated items. Treated clothing remains protective after multiple washings. See product information to learn how long the protection will last. If treating items yourself, follow the product instructions carefully. Do NOT use permethrin products directly on skin. They are intended to treat clothing.

8.5. Indoor Protection:

Stay in places with air conditioning or that use window and door screens to keep mosquitoes outside. Sleep under a mosquito bed net if air conditioned or screened rooms.

9. RESEARCH:

1) Public health research is critical for establishing the causal link between Zika virus infection in pregnant women and microcephaly in their babies and for understanding the pathogenesis of Zika virus infection.

2) A meeting on defining the public health research agenda is being organized by PAHO in Washington, D.C. from 1 to 2 March 2016 which will include a workshop with Global Outbreak Alert and Response Network (GOARN) technical partners.

3) A global consultation on research related to Zika virus infection will be held from 7 to 9 March 2016 to assess the research landscapes and plan for additional research. [32-36]

9.1. Summary of recommendations for clinicians and public health practitioners:

1. Zika virus infection should be considered in patients with acute fever, rash, arthralgia or conjunctivitis, who have travelled in the two weeks prior to onset of illness to areas with current or recent outbreaks or transmission; refer to the Department of Health webpage for the current country list.

2. All travellers should take steps to avoid mosquito bites in order to prevent Zika virus infection and other mosquito-borne diseases such as dengue, malaria and chikungunya.

3. Until more is known about Zika virus transmission in pregnancy and the association with adverse fetal outcomes, pregnant women are advised to consider postponing travel to any area where Zika virus transmission is ongoing. Pregnant women who do decide to travel to one of these areas are advised to consult with a doctor first and strictly follow mosquito bite prevention measures during their trip. Women trying to become pregnant are advised to consult with a doctor before travelling and strictly follow mosquito bite prevention measures.

4. Women who have returned from a Zika virus-affected area and who are pregnant are advised to consult a doctor and be evaluated, refer to Interim recommendations for assessment of pregnant women returning from Zika virus-affected areas. Men who have returned from Zika virus-affected areas and have a partner who is pregnant or planning pregnancy are advised to consult.

5. Doctor to discuss recommendations for preventing sexual transmission, refer to Interim recommendations for reducing the risk of sexual transmission of Zika virus. Zika virus infection is notifiable in Australia as a Flavivirus (unspecified) infection and should be notified to state and territory health departments.

6. In north Queensland and parts of central Queensland where suitable mosquito vectors are present, clinicians should immediately report clinically suspected cases of Zika virus infection to local public health units, as they do for suspected cases of dengue. Public health Authorities will take action mitigate the risk of local transmission.

7. Zika virus is a flavivirus, closely related to dengue. It is transmitted to humans primarily through the bite of certain infected Aedes species mosquitoes. Aedes aegypti mosquitoes are commonly found in tropical and sub-tropical regions around the world including north Queensland and some areas in central Queensla. Another similar mosquito, Aedes albopictus, also has the potential to transmit Zika virus, but in Australia is only found in the Torres Strait. These mosquito vectors typically breed in domestic water-holding containers; they are daytime biters and feed both indoors and outdoors near dwellings.

8. Outbreaks of Zika virus are currently of have previously been reported in tropical Africa, Southeast Asia, the Americas and the Pacific Islands. Zika can be spread from a pregnant mother to her fetus during pregnancy. Infection during pregnancies is linked to birth defects in babies. Zika is spread mostly by being bitten by an infected Aedes species mosquito.[38-42]

10. SUMMARY:

An Emergency Committee was convened by the Director-General under the International Health Regulations (2005) on 1 February 2016. Following the advice of the Committee, the Director-General announced the recent cluster of microcephaly and other neurologic disorders reported in Brazil to be a Public Health Emergency of International Concern. The Emergency Committee agreed that a causal relationship between Zika infection during pregnancy and microcephaly is strongly suspected, though not yet scientifically proven. All experts agreed on the urgent need to coordinate international efforts to investigate and understand this relationship better. Between January 2014 and 5 February 2016, a total of 33 countries have reported autochthonous circulation of Zika virus. There is also indirect evidence of local transmission in 6 additional countries. The geographical distribution of Zika virus has been steadily increasing since it was first detected in the Americas in 2015. Further spread to countries within the geographical range of competent disease vectors Aedes mosquitoes is considered likely. Seven countries have reported an increase in the incidence of cases of microcephaly and Guillain-Barre syndrome concomitantly with a Zika virus outbreak. The global prevention and control strategy launched by WHO is based on surveillance, response activities, and research.[36-38]

11. ACKNOWLEDGEMENT:

The authors are grateful to the authorities of I B S S.College of Pharmacy, Malkapur for the facilities.

12. CONFLICT OF INTEREST:

The authors declare no conflict of interest.

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Received on 06.03.2017 Modified on 20.03.2017

Res. J. Pharmacology & Pharmacodynamics.2017; 9(2): 101-114.

DOI: 10.5958/2321-5836.2017.00019.2