This document provides an overview and summary of Zika virus. It discusses what Zika virus is, how it spreads, its symptoms, diagnosis and treatment. It focuses particularly on the association between Zika infection during pregnancy and microcephaly in infants. It provides recommendations for prevention, discusses implications for global travel and the Rio Olympics, and politics surrounding the virus. The expert presenting is the Director of Medical Operations at Elite Medical Group with experience in emergency medicine.

1. ZIKA: WHAT YOU NEED TO KNOW
Devon L. Davis, MD
Director, Medical Operations
Elite Medical Group

2. PURPOSE OF PRESENTATION
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• Explore the virus and emerging problems worldwide
• Review symptoms, diagnosis and treatment
• Focus on special cases
• Target prevention strategies
• Discuss global implications

3. Global Rescue’s Boston Operations Center
GLOBAL RESCUE
Founded in 2004, U.S. based integrated
provider of:
• Medical Services
• Security Services
• Field Rescue Services
• Intelligence, Information & Mobile
Communication Services
• Crisis Planning & Response Services
Operations Centers located in:
• Massachusetts
• New Hampshire
• Pakistan
• Thailand
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4. DEVON L. DAVIS, MD
Director – Medical Operations, Elite Medical Group
Oversees worldwide medical operations for Elite Medical Group.
Board-certified Emergency Physician with 19 years of clinical practice.
• Extensive experience as medical director of multiple emergency medical service agencies
with emphasis on mass casualty events.
• Senior Doctor for Norwegian Cruise Line.
Education
• Residency-University of Pittsburgh Affiliated Residency in Emergency Medicine
• MD-Vanderbilt University School of Medicine
• BA-Dartmouth College
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5. INTRODUCTION
‘Zika’ has become a household word in the past 6-12
months due to:
• Its rapid spread in multiple countries
• Its impact on international travel
• The significant health implications for adults, children, and
particularly unborn fetuses
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6. Single-stranded RNA Arbovirus-
Flavivirus:
• 1947: Discovered in the Ugandan
Zika Forest in rhesus monkey with a
fever
• 1952: First human diagnosis
• 1953-2006: Occasional outbreaks;
likely many more cases than
reported
• 2007: Yap State, Federated States
of Micronesia;
• 2013-2014: French Polynesia
WHAT IS ZIKA?
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7. • May 2015: 1st confirmed case in
Brazil
• February 2016: Zika declared a
PHEIC (Public Health Emergency
of International Concern) by
World Health Organization
WHAT IS ZIKA? (CONT.)
PHEIC
“An extraordinary event which is
determined to constitute a public
health risk to other states through
the international spread of disease
and to potentially require a
coordinated international response.”
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8. Bites of Aedes aegypti or Aedes albopictus mosquitoes,
which:
• Also spread Dengue and Chikungunya
• Live near people
• Bite mostly in the daytime — dawn to dusk
• Often feed on multiple people for one blood meal
• Lay eggs in standing water (up to 200 eggs/3 days)
• “Cockroach” of the mosquito — very hardy
• Eggs can remain dry up to 1 year then hatch with water contact
TRANSMISSION
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9. Zika can also be passed from a mother to unborn fetus
• Now linked to severe birth defects such as microcephaly
Sexual contact:
• Virus persists longer in semen than in blood
• Can be passed from male to his partner
• Currently no evidence yet that can be passed from female to partner
Blood transfusion
Laboratory exposure — route is unclear
TRANSMISSION (CONT.)
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10. WHERE IS ZIKA FOUND?
• <2015: Mostly in Africa, Southeast Asia, Pacific
Islands
• May 2015: Brazil
• 2015-2016: Many countries, especially the
Americas
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11. CDC: ZIKA-ACTIVE COUNTRIES
Image: http://www.cdc.gov/zika/geo/active-countries.html
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12. Endemic countries have had Zika in the past and have
occasional new cases:
• Provides immunity to the local inhabitants
• Reduced risk to travelers
Epidemic countries have current outbreaks and have not had
Zika in the past:
• Little immunity for locals
• Higher risk to travelers
ENDEMIC VS. EPIDEMIC
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13. CDC Data as of July 6, 2016 U.S.:
• No locally-acquired mosquito-transmitted cases in US
• 1,132 travel-acquired cases
• 1 lab-acquired case
• 14 sexually-transmitted cases
• 5 cases of subsequent Guillain-Barré Syndrome
• 1 death (?)
US territories:
• 2,526 locally-acquired
• 8 travel-associated
• 12 cases of GBS
• Sexually transmitted not reported in mosquito-borne illness areas
• 1 death (thrombocytopenia)
US DATA
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14. • Fever, joint/muscle pain, rash, conjunctivitis, headache
• Symptoms usually last a few days to a week—mostly mild—”flu”
• Incubation period not well known
• Many asymptomatic (up to 80%) or mild disease
• Few hospitalizations/deaths
• Infection likely gives future immunity
• Similar to other mosquito-borne diseases like Dengue and
Chikungunya
ZIKA PRESENTATION
Image: cbc.ca/news/health/zika-virus-skin-1.3576971
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15. Zika can be a clinical diagnosis but can be tested in both blood and urine
by RT-PCR
Ab testing less reliable due to cross-reactivity with other viruses
Disease typically self-limiting :
• Oral fluids, rest, and anti-pyretics like Tylenol usually sufficient
• Hospitalization rarely needed
• Avoid NSAIDs/Aspirin until confirmed that not Dengue
(bleeding complications with Dengue)
• Avoid mosquito bites during first week of illness
—can spread to others via mosquitos
No vaccine available
DIAGNOSIS AND TREATMENT
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16. • Dengue
• Chikungunya
• Yellow Fever
• Malaria
• West Nile Virus
• Eastern/Western Equine Encephalitis
• St. Louis Encephalitis
• LaCrosse Encephalitis
• Zika
MOSQUITO-BORNE ILLNESSES
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17. PROBLEMS WITH ZIKA
Majority of cases of Zika infection resolve without incident
Several instances with far-reaching negative implications:
• Pregnancy
• Sexual transmission
• Post-viral sequelae
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18. • Certain birth defects in fetuses or infants born to mothers
infected with Zika
• CDC and WHO cautions to women who live in Zika-infected
areas or who are traveling to Zika prevalent areas
• Cautions also to couples about protected intercourse or
abstention
• Breastfeeding still recommended (currently)
ZIKA AND PREGNANCY
Image: africa.tvcnews.tv
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19. • Since May 2015 outbreak in Brazil, significant
increase in babies born with microcephaly
(small head) & other defects
• Rare: 6/10,000 births in US
• Causes: genetic, infection (rubella, CMV),
severe malnutrition, exposures to
ETOH/chemicals, poor blood supply to brain in
utero
• Increase in instances of microcephaly in babies
with mothers positive for Zika has caused great
concern worldwide
MICROCEPHALY
Image: cdc.gov/ncbddd/birthdefects/microcephaly.html
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20. • A spectrum of severity from mild to severe
• Seizures, vision/hearing disorders, movement/balance problems,
developmental and intellectual delay, difficulty swallowing
• Can be noted on ultrasound but not very sensitive
• After birth head circumference remains <3rd percentile
• No cure or treatment
• Fetal brain disruption sequence-collapse of skull after destruction
of brain tissue
• Congenital Zika Syndrome: severe microcephaly, other brain & eye
abnormalities, redundant scalp skin, arthrogryposis, clubfoot
MICROCEPHALY (CONT.)
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21. SLIDE 21

22. Case report from New England Journal of Medicine –
March 2016:
• 25 yo healthy female from Slovenia, a volunteer in Brazil since 2013
• Pregnant in Feb. 2015 febrile illness with itchy rash at 13 weeks
• No testing for Zika done at the time
• U/S @ 14 and 20 weeks unremarkable
• Returned to Europe – U/S @ 29 weeks showed fetal defects
• Presented to Dept. of Perinatology in Ljubljana, Slovenia
• Pregnancy terminated @32 weeks – severe microcephaly and other
significant defects
• Pathology indicated Zika virus in brain tissue
MICROCEPHALY (CONT.)
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23. • Search for causality for the microcephalic babies in Brazil
• Reviewed the data using methods for determining teratogenicity
• 2013-14 outbreak in French Polynesia noted similar increase in
microcephalic infants
• Defects consistent with infection during 1st or 2nd trimester
• Conclusion: +causal relationship between a Zika-infected mother
and microcephaly, other birth defects
NEW ENGLAND JOURNAL OF MEDICINE - MAY 2016
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24. RECOMMENDATIONS FOR PREGNANCY
Virus remains in semen longer than in blood; exact duration not
clear
Pregnant women who live in or have traveled to Zika areas:
• Use condoms or abstain from intercourse during the pregnancy;
• Prevent further mosquito bites
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25. Testing:
• Pregnant women w/potential exposure should be tested if either
she or partner develops symptoms
• Pregnant women who have visited a Zika area should be tested and
have ultrasounds during pregnancy, even if asymptomatic
• Not as useful to test male partner—false negatives; virus may still
be in semen but not in blood; Ab level often not detectable
• No attempt at pregnancy recommended for 8 weeks after leaving
Zika-prevalent country
RECOMMENDATIONS FOR PREGNANCY (CONT.)
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26. SEXUAL TRANSMISSION
Zika virus can be passed through sexual contact
First documented case 2008
Via oral, vaginal or anal intercourse
• Known that can pass from male to his partner
• Unclear if female can spread virus to her partner
—currently no known cases
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27. • Virus can be transmitted before or after symptoms appear or
even without symptoms
• Virus found in blood, semen, urine, saliva, breast milk but
not vaginal swabs
• Virus persists longer in semen than in blood—isolated from
semen weeks after illness onset when blood negative
• Condoms or abstinence provide best protection
• Not clear if birth defects same if disease acquired through
sexual contact vs. mosquito bite
SEXUAL TRANSMISSION (CONT.)
Image: webmd.com/sex/rm-quiz-condoms
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28. Travelers to Zika areas:
• Male partner with symptoms: condoms/no sex for 6 months
• Male partner without symptoms: condoms/no sex for 8 weeks after
return
Living in Zika areas:
• Male partner with symptoms: condoms/no sex for 6 months
• Male partner without symptoms: consider precautions while Zika is in
the area
SEXUAL TRANSMISSION (CONT.)
Image: webmd.com/sex/rm-quiz-condoms
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29. • Increase in cases of Guillain-Barré Syndrome
noted in patients s/p Zika illness
• GBS is an autoimmune disease that attacks
the peripheral nervous system
• Causes an ascending flaccid paralysis and
sensory loss
• More common in adults than children
• Most recover-some serious cases have long-
term complications, can be deadly
• Often triggered by viral or bacterial
infection or other stressors (surgery,
trauma, or rarely immunizations)
• Diagnosed by loss of DTR’s, lumbar puncture
• No cure-mostly supportive treatment (IV
immunoglobulin and plasmapheresis may be
helpful)
GUILLAIN-BARRÉ SYNDROME
Image: medicalnewstoday.com/articles/167892.php
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30. NEJM April 2016 article:
• Possible mutation that gives the current strain increased virulence and
ease of transmission
• Don’t see incidence of microcephaly and Guillain-Barré
• Syndrome in endemic areas of Zika—likely because most children have
contracted the disease at some point. Children less likely to have GBS. They
are likely immune by the time old enough for pregnancy.
GUILLAIN-BARRÉ SYNDROME (CONT.)
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31. DR. MARIA ADELAIDA VELEZ GARCIA
—OB/GYN IN CALI, COLOMBIA
• 2500 patients/year (1,800 OB, consults on additional 1,200)
• December 2015 – June 2016: 21 pregnant patients + for Zika
• 10 fetuses with microcephaly or other defects, including
intracranial calcifications, poor brain development – 5 were
aborted
• Study from Brazil had a birth defect rate of about 29%
Image: en.Wikipedia.org/wiki/Cali
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32. “Preliminary surveillance data in Colombia suggests
that maternal infection with the Zika virus during the
third trimester of pregnancy is not linked to
structural abnormalities in the fetus. However, the
monitoring of the effect of ZVD on pregnant women
in Colombia is ongoing.”
JUNE 2016 NEJM: COLOMBIA
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33. Letter to the Editor:
Authors’ research has shown an increase in requests
for abortion medications through the Internet in
Latin American countries that either restrict or
prohibit abortion.
JUNE 2016 NEJM
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34. • No vaccine
• Avoiding bites by the Aedes mosquito is the best way to prevent
infection with Zika virus
• Use insect repellents that contain DEET, picardin, IR3535 or oil of
lemon & eucalyptus or para-menthane-diol products
• Sunscreen first
• Wear long sleeves, long pants and/or permethrin-treated clothing
• Use air conditioning and screens in windows or mosquito netting
• Get rid of standing water
• Vector control—eggs and adult mosquitos
PREVENTION
Image: wikihow.com/apply-deet
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35. GLOBAL IMPLICATIONS
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36. APRIL 14, 2016 SLIDE 36
RIO OLYMPIC GAMES

37. 238-physician letter to the WHO (June 2016)
Multiple athletes dropping out
International Journal of Infectious Diseases (Feb. 2016)
—preparedness for mass gatherings:
• Vector control by Brazilian government
• Increased awareness
• Improved testing capability
• Facilities for treatment of sequelae/complications
• Education of athletes and visitors in prevention
Winter season in Brazil (fewer mosquitoes)
July 2016, The Lancet: Zika risk for Rio games 15x LESS than risk
of Dengue during 2014 World Cup in Brazil
RIO OLYMPICS
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38. CDC recommendations for travelers:
• Pregnant women—not to any area with
Zika
• If must, should follow guidelines for
mosquito bite prevention
• Get good prenatal care including testing
with or without symptoms
Safe sex for all travelers
Use preventive measures
After return home:
• Avoid mosquito bites for several weeks
• Safe sex for 8 weeks (6 months if male
has symptoms; male partners of
pregnant women—condom use or
abstention until pregnancy over)
INTERNATIONAL TRAVEL
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39. SPREAD OF ZIKA
Current outbreak spread quickly to a multitude of countries
Asian strain (French Polynesia, Cambodia, Yap)
Spread by mosquitoes:
• Aedes aegypti located in warmer zones
• Aedes albopictus can survive cooler temps
Image: www.nejm.org/doi/full/10.1056/nejmra12602113 figure 3
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40. Zika mosquitoes do not like to live at altitudes greater than 6500ft
(2000m) above sea level
Some feel that an outbreak in the US is unlikely:
• Even warmer states get cool temps in the winter months
• Advanced countries have increased use of air conditioning and
window screens
• Proactive vector control including aerial spraying for mosquitos
Puerto Rico and aerial spraying
Travelers returning from Zika areas must avoid mosquito bites
Concerns for worldwide spread still exist…
SPREAD OF ZIKA (CONT.)
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41. US AREAS OF RISK
Image: www.nejm.org/doi/full/10.1056/nejmra12602113 figure 3
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42. POLITICS, RELIGION AND THE MEDIA
• May 2016 and July 2016 - Director of CDC makes pleas for federal funding for
Zika
• US Congress controversy
• MDs’ letter to WHO ran on CNN + other news stations
• Started with 100 signatures
• Now nearly 240
• Pop media and Internet sites postulate every theory from Olympics problems to
population control/terrorism
• Pope Francis has even weighed in
Image: www.nejm.org/doi/full/10.1056/nejmra12602113 figure 3
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43. Zika is an international public health
problem
Spread must be controlled
Need research into:
• Vaccine
• Rapid diagnosis
• Treatment
• Prevention
• Zika as cause of birth defects and
Guillain-Barré Syndrome
CONCLUSIONS
Image: huffingtonpost.com/entry/faqs-about-zika-virus_us_56ae80c9e4b077d4fe8e8f6c
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44. 15.“El Salvador confirms second case of Zika-linked
microcephaly,” Fox News, July 11, 2016.
16.“El Salvador confirms second case of Zika-linked
microcephaly,” Fox News, July 11, 2016.
17.“CDC Head Tom Frieden Delivers Emotional Plea for Zika
Funding,” Huffington Post, May 26, 2016.
18.“Utah resident is first Zika-related death in continental US,”
CNN, July 8, 2016.
19.“Utah woman is 1st confirmed Zika-related death in
continental US,” FoxNews.com, July 9, 2016.
20.“Officials confirm Zika-related death in Utah was a man,”
Washington Post, July 11, 2016.
21.“On Zika, Obama warns congressional inaction could cause
‘tragedies that can last a lifetime,’” Washington Post, July 1,
2016.
22.“White House threatens to veto $1.1 GOP Zika bill, “ Fox
News, June 23, 2016.
23.“Amid Zika Crisis, House GOP Proposes Eliminating Birth
Control Program,” Huffington Post, July 6, 2016.
24.“Brazil says the is ‘almost zero’ risk of Zika during Olympics.
Really?” Washington Post, July 6, 2016.
25.US Reports 279 Zika cases in pregnant women, Obama pushes
Congress on funds,” The Himalayan, May 21, 2016.
26.“Climate Change Bites,” nrdc.org, December 31, 2015
27.“Pope Francis suggests contraception could be permissible in
Zika fight,” Washington Post, February 18, 2016.
28.“the Real Surprise in Pope Francis’ Zika virus remarks,”
religionnews.com, February 19, 2016.
29.“US Centers for Disease Control and Prevention and
Environmental Protection Agency Urge Commonwealth of Puerto
Rico to Consider Aerial Spraying as Part of Integrated Mosquito
Control to Reduce Zika-Associated Birth Defects,” CDC Media
Statement, July 6, 2016.
30.“US Reports First Zika Virus Death in Puerto Rico,”
nbcnews.com, April 29, 2016.
31.“Pope Francis: Abortion is evil, not the solution to Zika
virus,” catholicnewsagency.com, February 18, 2016 .
REFERENCES
1.Pacheco, Oscar et al. Zika Virus Disease in Colombia—
Preliminary Report. N Engl J Med Online. June 15, 2016.
2.Petersen, Lyle R. et al. Zika Virus. N Engl J Med 2016; 374:
1552-1563.
3.Massad, Eduardo et al. Is Zika a substantial risk for visitors to
the Rio de Janeiro Olympic Games? The Lancet 2016; Vol. 388,
No. 10039, p.25.
4.Mlakar, Jernej et al. Zika Virus Associated with Microcephaly .
N Engl J Med 2016; 374:951-958.
5.Rasmussen, Sonja A. et al. Zika Virus and Birth Defects—
Reviewing the Evidence for Causality . N Engl J Med 2016; 374:
1981-1987.
6.Franca, Giovanny VA et al. Congenital Zika virus syndrome in
Brazil: a case series of the first 1501 live births with complete
investigation. The Lancet Online. June 29, 2016.
7.Letter to Editor. Requests for Abortion in Latin America
Related to Concern about Zika Virus Exposure. N Engl J Med.
June 22, 2016.
8.Petersen, Eskild et al. Unexpected and Rapid Spread of Zika
Virus in the Americas-Implications for Public Health
Preparedness for Mass Gatherings at the 2016 Brazil Olympic
Games. International Journal of Infectious Diseases 2016; 44 :
11-15.
9.Musso, D. et al. Rapid Spread of Emerging Zika Virus in the
Pacific Area. Clinical Microbiology and Infection 2014; Vol. 20,
Issue 10: 595-596.
10.Besnard, M. et al. Evidence of Perinatal Transmission of Zika
Virus, French Polynesia, December 2013 and February 2014 .
Eurosurveillance 2014; Vol. 19, Issue 13.
11.CDC website: www.cdc.gov
12.WHO website: www.who.int/
13.Mosquito-Borne Diseases. American Mosquito Control
Association.
14.“As New Olympians Celebrate Victory, Families Contemplate
Safety,” New York Times, July 3, 2016.
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45. QUESTIONS?
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