Zika Virus Infection - An Overview - UpToDate

29/9/2016
Zikavirusinfection:AnoverviewUpToDate
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate
Zikavirusinfection:Anoverview
Author: A.DesireeLaBeaud,MD,MS
SectionEditor: MartinSHirsch,MD
DeputyEditor: ElinorLBaron,MD,DTMH
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Aug2016.|Thistopiclastupdated:Sep26,2016.
INTRODUCTIONZikavirusisanarthropodborneflavivirustransmittedbymosquitoes[14].Thevirusisrelatedtootherflavivirusesincluding
denguevirus,yellowfevervirus,andWestNilevirus.ClinicalmanifestationsofZikavirusinfectionoccurinapproximately20percentofpatientsand
includeacuteonsetoflowgradefeverwithmaculopapularpruriticrash,arthralgia(notablysmalljointsofhandsandfeet),orconjunctivitis
(nonpurulent).
NeurotropismofZikavirushasbeendemonstratedinvivoandinvitro[59].Zikavirusinfectionhasbeenassociatedwithneurologiccomplications
theseincludecongenitalmicrocephaly(inadditiontootherdevelopmentalproblemsamongbabiesborntowomeninfectedduringpregnancy),Guillain
Barrsyndrome,myelitis,andmeningoencephalitis[1012].(See'Complications'below.)
Currently,thereisanongoingZikavirusoutbreakintheAmericas,theCaribbean,andthePacifictheWorldHealthOrganization(WHO)hasstated
thatthevirusis"spreadingexplosively"[13]andhasdeclaredZikavirusanditsassociatedcomplicationsaPublicHealthEmergencyofInternational
Concern[14].
OnlineupdatesregardingZikavirusinfectionmaybeviewedatthefollowingwebsites:
PanAmericanHealthOrganization(PAHO)/WHOwebsite
UnitedStatesCentersforDiseaseControlandPrevention(CDC)website
EuropeanCentreforDiseasePreventionandControl(ECDC)website
GeneralissuesrelatedtoZikavirusepidemiologyandpreventionarereviewedhere.IssuesrelatedtoZikavirusinfectioninpregnantwomenand
infantswithcongenitalexposurearediscussedseparately.(See"Zikavirusinfection:Evaluationandmanagementofpregnantwomen".)
EPIDEMIOLOGY
GeographicdistributionOutbreaksofZikavirusinfectionhaveoccurredinAfrica,SoutheastAsia,andthePacificIslandscurrently,thereisan
ongoingZikavirusoutbreakintheAmericas,theCaribbean,andthePacific[1517].UpdatesregardingthegeographicdistributionofZikavirusmaybe
https://www.uptodate.com/contents/zikavirusinfectionanoverview/print?source=search_result&search=zika&selectedTitle=2~57
1/28
29/9/2016
viewedattheUnitedStatesCentersforDiseaseControlandPreventionwebsiteandthePanAmericanHealthOrganization/WorldHealthOrganization
website.
ZikavirusisnamedaftertheUgandanforestwhereitwasfirstisolatedfromarhesusmonkeyin1947[18].Thefirsthumancasesweredetectedin
1952inUgandaandTanzania.ThevirussubsequentlyspreadacrossequatorialAfricaandAsia,whereitwasassociatedwithsporadicinfections.The
firstmajorrecognizedoutbreakoccurredintheYapIslandsofMicronesiain2007morethan70percentofthepopulation3yearsofagewasinfected,
resultinginanestimated5000infectionsamongthetotalpopulationof6700[1921].AnotherlargeroutbreakoccurredinFrenchPolynesiain2013to
2014,whichaffectedabouttwothirdsofthepopulation,resultinginapproximately32,000infections[22,23].DuringtheoutbreakinFrenchPolynesia,3
percentofdonatedbloodsamplestestedpositiveforZikavirusbypolymerasechainreaction[24].
ZikavirusinfectionswerefirstdetectedintheWesternhemisphereinFebruary2014onChile'sEasterIsland[25].Zikavirusinfectionswere
subsequentlydetectedinBrazilinMay2015[25].Molecularanalyseshavesuggestedthatthevirusmayhavebeenintroducedearlier,inlate2013or
early2014[26].RegionswithmosquitobornetransmissionofZikavirusaresummarizedbelow.(See'Traveladvisoriesforpregnantwomen'below.)
IntheUnitedStates,mosquitobornetransmissionhasoccurredinFlorida,andimportedZikainfectionhasbeenreportedintravelers[2729].Inone
reportfromNewYorkCityincluding3605individualswithtravelassociatedexposurewhounderwentZikaviruslaboratorytestingbetweenJanuaryand
June2016,positiveresultswereobservedin182patients(5percentofcases),including20pregnantwomen[30].ThefirstcaseofZikarelated
congenitalmicrocephalyintheUnitedStateswasreportedinJanuary2016inHawaii,inababyborntoawomanwhohadresidedinBrazilduringher
pregnancy[31].ThefirstcaseofsexuallytransmittedZikavirusinfectionintheUnitedStateswasreportedinTexasinFebruary2016[32].
TraveladvisoriesforpregnantwomenGivenanassociationbetweenZikavirusexposureduringpregnancyandcongenitalmicrocephaly,a
numberofauthoritieshaveadvisedthatpregnantwomenavoidorconsiderpostponingtraveltoareasbelow6500feet(2000meters)wheremosquito
transmissionofZikavirusisongoingtheseareasaresummarizedbelow[3338].Regionsabove6500feet(2000meters)areexcludedfromtravel
precautions,sincethemosquitoesthattransmitZikavirusarerareintheselocationsandtheriskformosquitobornetransmissionofZikavirusis
minimal[38].
CountriesandterritorieswithlocalmosquitobornetransmissionofZikavirusincludeAnguilla,AntiguaandBarbuda,Argentina,Aruba,TheBahamas,
Barbados,Belize,Bolivia,Bonaire,Brazil,theBritishVirginIslands,CapeVerde,CaymanIslands,Colombia,CostaRica,Cuba,Curaao,Dominica,
DominicanRepublic,Ecuador,ElSalvador,Fiji,FrenchGuiana,Grenada,Guadeloupe,Guatemala,Guyana,Haiti,Honduras,Jamaica,Kosrae
(FederatedStatesofMicronesia),MarshallIslands,Martinique,Mexico,NewCaledonia,Nicaragua,Panama,PapuaNewGuinea,Paraguay,Peru,
Saba,Samoa,SaintBarthlemy,SaintLucia,SaintMartin,SaintVincentandtheGrenadines,Singapore,SintEustatius,SintMaarten,Suriname,
Tonga,TrinidadandTobago,TurksandCaicos,theUnitedStates,andVenezuela[34,39,40].
WithintheUnitedStates,mosquitobornetransmissionofZikavirusinfectionhasoccurredinFloridapregnantwomenareadvisedtoavoidtraveltoan
areaofMiamiBeach[41,42].TheWynwoodareaofMiamiwasanactivetransmissionareafromJune15toSeptember18,2016theadvisorywas
liftedafterthreemosquitoincubationperiodspassedwithnonewlocallytransmittedcasesofZikavirusinfection[41].Inaddition,mosquitoborneZika
virustransmissioninPuertoRicohasbeenextensive[43,44].ThereisalsomosquitobornetransmissionofZikavirusintheUnitedStatesterritoriesof
theVirginIslandsandAmericanSamoa.
2/28
29/9/2016
TransmissionZikavirusmaybetransmittedtohumansviathefollowing[24,32,4551]:
Biteofaninfectedmosquito
Maternalfetaltransmission
Sex(includingvaginal,anal,andoralsex)
Bloodproducttransfusion
Organtransplantation
Laboratoryexposure
Preventivemeasuresbasedonthevariousmodesoftransmissionarediscussedbelow.(See'Prevention'below.)
Theprimarymodeoftransmissionisviamosquitobites.ZikavirusiscarriedbytheAedesaegyptimosquito,whichlivesintropicalregionshowever,
theAedesalbopictusmosquito,whichlivesintemperateregions,isalsocapableofcarryingit(figure1andfigure2)[5255].Aedesmosquitoescan
alsotransmitdengueandchikungunyaviruses.(See'Mosquitoprotection'below.)
ZikavirusRNAhasbeendetectedinblood,urine,semen,saliva,femalegenitaltractsecretions,cerebrospinalfluid,amnioticfluid,andbreastmilk
[24,52,5662]:
BloodInnonpregnantindividualswithZikavirusinfection,ZikavirusRNAisdetectableintheserumforafewdaystoaweekZikavirusRNAis
detectableinwholebloodaslateas58daysfollowingonsetofillness[63].Inpregnancy,ZikavirusRNAhasbeendetectedintheserumaslateas
10weeksafteronsetofillness[64].
UrineZikavirusRNAhasbeendetectedinurineupto91daysafteronsetofillness[57,60,61,6567].Replicatingvirushasbeendetectedin
urineatthetimeofsymptomaticillness[68].
SemenZikavirusRNAhasbeendetectedinsemenupto188daysafteronsetofillnessitcanbedetectedinsemenwhennolongerdetectable
inblood[61,67,6971].Replicatingvirushasbeendetectedinsemen7daysafteronsetofillness[72].SexualtransmissionofZikavirusaslateas
41daysafteronsetofapartner'ssymptomshasbeendescribed[47,73].Theviralloadinsemenmaybehighinonereport,theviralloadin
semenmorethantwoweeksafteronsetofsymptomswasroughly100,000timesthatofbloodorurine[74].
Aprobablecaseofmaletofemalesexualtransmissioninvolvinganasymptomaticmalehasalsobeenreported[75].
SalivaZikavirusRNAhasbeendetectedinsalivaupto91daysafteronsetofillness[58,61,67].Replicatingvirushasbeendetectedinsalivaat
thetimeofsymptomaticillness[68].
FemalegenitaltractsecretionsZikavirusRNAhasbeendetectedinfemalegenitaltractsecretions(viagenital,endocervicalswabs,andcervical
mucus)duringsymptomaticillness[62].ZikavirusRNAhasalsobeendetectedincervicalmucus11daysafteronsetofillness,whenitwasno
longerdetectableinbloodorurine[62].
3/28
29/9/2016
Humantohumantransmissionapartfromsexualtransmissionhasbeendescribed[76].Themodeoftransmissioninthecasedescribedisuncertain
closecontactoccurredwhiletheindexpatientsviralloadwasveryhigh,anditispossiblethatbloodandbodyfluidsofpatientswithZikavirusdisease
couldbeinfectious.
Issuesrelatedtomaternalfetaltransmissionandbreastfeedingarediscussedseparately.(See"Zikavirusinfection:Evaluationandmanagementof
pregnantwomen",sectionon'Congenitalinfection'.)
TheWorldHealthOrganizationhasissuedrecommendationsforpreventionofZikavirusinfectionforindividualsplanningtotraveltoBrazilforthe
OlympicGamesinAugust2016[77].
CLINICALMANIFESTATIONSTheincubationperiodbetweenmosquitobiteandonsetofclinicalmanifestationsistypically2to14days.Theillness
isusuallymildsymptomsresolvewithintwotosevendays.Immunitytoreinfectionoccursfollowingprimaryinfection[78].Severediseaserequiring
hospitalizationisuncommon,andcasefatalityratesarelow[7983].
Symptomsandsigns
AdultsSymptomsandsignsofZikavirusinfectiontypicallyincludeacuteonsetoflowgradefever(37.8to38.5C),maculopapularpruriticrash,
arthralgia(notablythesmalljointsofhandsandfeet),andconjunctivitis(nonpurulent)clinicalillnessisconsistentwithZikavirusdiseaseiftwoormore
ofthesesymptomsarepresent[33,8486].Othercommonlyreportedclinicalmanifestationsincludemyalgia,headache,retroorbitalpain,andasthenia
[79].Lesscommonlyobservedsymptomsandsignsincludeabdominalpain,nausea,diarrhea,andmucousmembraneulcerations[87].
Thrombocytopenia,palatalpetechiae,anduveitishavebeendescribedincasereports[8892].
ClinicalmanifestationsofZikavirusinfectionoccurin20to25percentofindividualswhobecomeinfectedwithZikavirus.Outsideareaswithmosquito
transmission,thelikelihoodofZikavirusinfectionamongasymptomaticindividualsislow[93].
ChildrenTherangeofZikavirusinfectioninchildrenincludesintrauterineinfection(verticaltransmissionduringpregnancy),intrapartuminfection
(verticaltransmissionatthetimeofdelivery),andpostnatalinfection(transmissionviamosquitobites).Issuesrelatedtointrauterineandintrapartum
infectionarediscussedseparately.(See"Zikavirusinfection:Evaluationandmanagementofpregnantwomen".)
ClinicalmanifestationsininfantsandchildrenwithpostnatalinfectionaresimilartothefindingsseeninadultswithZikavirusinfection[20,94].Arthralgia
isdifficulttodetectininfantsandyoungchildrenandmaymanifestasirritability,walkingwithalimp,difficultymovingorrefusingtomoveanextremity,
painonpalpation,orpainwithactiveorpassivemovementoftheaffectedjoint[94].Thusfar,nodevelopmentalcomplicationshavebeenobservedin
otherwisehealthychildrenwithpostnatalZikavirusinfection[95,96].(See"Evaluationofthechildwithjointpainand/orswelling".)
ComplicationsZikavirusinfectionhasbeenassociatedwithcomplicationsincludingcongenitalmicrocephalyandfetallossesamongwomen
infectedduringpregnancy,aswellasneurologiccomplications.Issuesrelatedtocongenitalinfectionarediscussedseparately.(See"Zikavirus
infection:Evaluationandmanagementofpregnantwomen".)
GuillainBarrsyndromeSeveralcountriesintheAmericashavereportedunusualincreasesincasesofGuillainBarrsyndrome(GBS)in
parallelwiththeongoingZikavirusoutbreak[97100].AnincreaseintherateofGBSinassociationwithZikavirusinfectionhasalsobeenobservedin
4/28
29/9/2016
otherreports[56,101106].
AcasecontrolstudyinFrenchPolynesiaevaluatedtheassociationbetweenGBSandZikavirusinfectionduringthe2013to2014outbreak[105].
Casesincluded42patientsdiagnosedwithGBSonecontrolgroupincluded98patientswithnonfebrileillnesses(matchedforage,sex,and
residence),andasecondcontrolgroupincluded70patientswithZikavirusinfectionintheabsenceofneurologicalcomplications.Zikaimmunoglobulin
(Ig)Mwaspositivein93percentofGBScases(versus17percentofpatientsinthefirstcontrolgroup)serologicevidenceofpastdengueinfectionwas
similaramongallthreegroups.AntiglycolipidIgGantibodiesweredetectedinfewerthan50percentofGBScases,raisingthepossibilityofdirectviral
neurotoxicity.ResultsofnerveconductionstudieswereconsistentwiththeacutemotoraxonalneuropathytypeofGBSclinicalimprovementduring
followupsuggestedreversibleconductionfailure.SymptomsofZikavirusinfectionoccurredin88percentofpatientswithGBSthemedianinterval
betweenviralsyndromeandonsetofneurologicalsymptomswassixdays.AllGBScasesreceivedintravenousimmuneglobulin,38percentrequired
intensivecare,and29percentneededrespiratorycareallsurvived.TheincidenceofGBSduringtheoutbreakwasestimatedtobe2.4casesper
10,000Zikavirusinfections.
Issuesrelatedtodiagnosis,evaluation,andmanagementofGuillainBarrsyndromearediscussedfurtherseparately.(See"Clinicalfeaturesand
diagnosisofGuillainBarrsyndromeinadults"and"TreatmentandprognosisofGuillainBarrsyndromeinadults".)
OtherneurologiccomplicationsZikavirushasbeenassociatedwithotherneurologiccomplicationsincludingbrainischemia[81],myelitis
[107],andmeningoencephalitis[108,109].Theseentitiesarediscussedfurtherseparately.(See"Transversemyelitis"and"Viralencephalitisinadults".)
DIFFERENTIALDIAGNOSISThedifferentialdiagnosisofZikavirusinfectionincludes:
Otherviralcausesofarthritis:
DenguefeverDenguevirusandZikavirusinfectionshavesimilarclinicalmanifestationsandaretransmittedbythesamemosquitovector.
However,dengueinfectionusuallypresentswithhighfever,severemusclepain,andheadacheandmayalsobeassociatedwithhemorrhage
unlikeZikainfection,dengueistypicallynotassociatedwithconjunctivitis(table1).CoinfectionwithZika,chikungunya,anddengueviruses
hasbeendescribed[110].Thediagnosisofdenguevirusinfectionisestablishedviaserology.(See"Clinicalmanifestationsanddiagnosisof
denguevirusinfection".)
ChikungunyaChikungunyavirusandZikaviruscausesimilarsymptomsandsignsandaretransmittedbythesamemosquitovector.
However,chikungunyausuallypresentswithhighfeverandintensejointpainaffectingthehands,feet,knees,andbackunlikeZikainfection,
chikungunyaistypicallynotassociatedwithconjunctivitis(table1).Chikungunyainfectioncanbedisabling,causingpatientstobendoversuch
thattheycannotwalk,andinfectedindividualsmaybeunabletoperformsimplemanualtasks.CoinfectionwithZika,chikungunya,and
dengueviruseshasbeendescribed[110].Thediagnosisofchikungunyavirusinfectionisestablishedviaserology.(See"Chikungunyafever".)
ParvovirusParvovirusinfectioncanpresentwithacuteandsymmetricarthritisorarthralgia,mostfrequentlyinvolvingthesmalljointsofthe
hands,wrists,knees,andfeet.Rashmayormaynotbepresent.Thediagnosisisestablishedviaserology.(See"Clinicalmanifestationsand
diagnosisofparvovirusB19infection".)
5/28
29/9/2016
RubellaClinicalmanifestationsofrubellaincludelowgradefeverandcoryza.Macularrashbeginsonthefaceandspreadstothetrunk,and
arthritisandlymphadenopathymaybepresent.Thediagnosisisestablishedviaserology.(See"Rubella".)
Anumberofothervirusesincludingenterovirus,adenovirus,andalphavirusesmayalsocausearthritisthesearediscussedfurther
separately.(See"Specificvirusesthatcausearthritis".)
MeaslesClinicalmanifestationsofmeaslesincludefever,cough,sorethroat,coryza,conjunctivitis,andlymphadenitis.Koplikspotsmayprecede
thegeneralizedrash.Thediagnosisisestablishedviaserology.(See"Clinicalmanifestationsanddiagnosisofmeasles".)
LeptospirosisLeptospirosisischaracterizedbyfever,rigors,myalgia,conjunctivalsuffusion,andheadache.Lesscommonsymptomsandsigns
includecough,nausea,vomiting,diarrhea,abdominalpain,andarthralgia.ItmaybedistinguishedfromZikavirusinfectionbythepresenceof
jaundice.Thediagnosisisestablishedviaserology.(See"Epidemiology,microbiology,clinicalmanifestations,anddiagnosisofleptospirosis".)
MalariaMalariaischaracterizedbyfever,malaise,nausea,vomiting,abdominalpain,diarrhea,myalgia,andanemia.Thediagnosisofmalariais
establishedbyvisualizationofparasitesonperipheralsmear.(See"Clinicalmanifestationsofmalariainnonpregnantadultsandchildren".)
RickettsialinfectionRickettsialinfectionswithsimilarmanifestationsasZikavirusinfectionincludeAfricantickbitefeverandrelapsingfever.
AfricantickbitefeverisobservedamongtravelerstoAfricaandtheCaribbeanandischaracterizedbyheadache,fever,myalgia,solitaryor
multipleescharswithregionallymphadenopathy,andgeneralizedrashthediagnosisisestablishedviaserology.Relapsingfeverischaracterized
byfever,headache,neckstiffness,arthralgia,myalgia,andnauseadiagnostictoolsincludedirectsmearandpolymerasechainreaction.(See
"Otherspottedfevergrouprickettsialinfections"and"Clinicalfeatures,diagnosis,andmanagementofrelapsingfever".)
GroupAStreptococcusClinicalmanifestationsofgroupAStreptococcusinfectionincludefever,myalgia,cutaneousmanifestations(cellulitis,
fasciitis),pharyngitis,andshock.Thediagnosisestablishedbypositiveculturesfromthebloodorothertissues.(See"GroupAstreptococcal
(Streptococcuspyogenes)bacteremiainadults".)
DIAGNOSISTheapproachtoZikavirusdiagnosismayvarydependingonavailableresourcestheapproachoutlinedinthefollowingsectionsmay
needtobetailoredtolocalcircumstances.
ThediagnosisofZikavirusinfectionshouldbesuspectedinindividualswithtypicalclinicalmanifestationsandrelevantepidemiologicexposure
(residenceinortraveltoanareawheremosquitobornetransmissionofZikavirusinfectionhasbeenreported,orunprotectedsexualcontactwitha
personwhomeetsthesecriteria).
IssuesrelatedtodiagnosisofZikavirusinfectioninsymptomaticadults(pregnantandnonpregnant)andchildrenwithpostnatalinfectionarediscussed
below.
IssuesrelatedtodiagnosisofZikavirusinfectioninasymptomaticpregnantwomenandinfantswithpossiblecongenitalZikavirusexposureare
discussedseparately.(See"Zikavirusinfection:Evaluationandmanagementofpregnantwomen".)
6/28
29/9/2016
CasedefinitionsThefollowinginterimcasedefinitionshavebeenissuedbytheWorldHealthOrganization(WHO)toprovideglobalstandardization
forclassificationandreportingofZikaviruscases[111].
Asuspectedcaseisapersonwitharash(maculopapular)and/orfever(37.8to38.5C)withatleastoneofthefollowingsymptoms(notexplained
byothermedicalconditions):arthralgia,arthritis,orconjunctivitis(nonpurulent/hyperemic).Asuspectedcaseshouldalsohaverelevant
epidemiologicexposure(residenceinortraveltoanareawheremosquitobornetransmissionofZikavirusinfectionhasbeenreported,or
unprotectedsexualcontactwithapersonwhomeetsthesecriteria),eventhoughepidemiologicexposureisnotincludedintheWHO
categorizationofasuspectedcase.
Aprobablecaseisasuspectedcasewithimmunoglobulin(Ig)MantibodyagainstZikavirus(withnoevidenceofinfectionwithotherflaviviruses)
andrelevantepidemiologicexposure(asdescribedabove).
AconfirmedcaseisapersonwithlaboratoryconfirmationofZikavirusinfection,eitherbydetectionofviralRNAorantigeninserumorother
samplesorbydetectionofZikaIgMantibodyandapositiveZikavirusplaquereductionneutralizationtest(PRNT).PRNTisneededtodetermine
whetherapositiveIgMantibodyresultagainstZikavirusreflectsrecentZikavirusinfectionorafalsepositiveresult.
GuidanceissuedbytheUnitedStatesCentersforDiseaseControlandPrevention(CDC)indicatesaPRNTtitergreaterthan10shouldbe
interpretedasevidenceofinfectionwithaspecificflaviviruswhenthePRNTtotheotherflavivirusestestedislessthan10(table2)[112].This
guidancereflectsamoreconservativeapproachtointerpretingPRNTthanpreviouslyprovidedbytheWHO(PRNTtiter20andPRNTtiter4
comparedwithotherflaviviruses)[111],sinceafourfoldhighertiterbyPRNTmaynotreliablydiscriminatebetweenZikavirusantibodiesandcross
reactingantibodiesinallindividualswhohavepriorinfectionorvaccinationagainstarelatedflavivirus.
Fornonpregnantpatientsresidinginareaswheremosquitotransmissionhasbeenestablished,thediagnosisofZikavirusinfectionmaybesuggested
basedonsymptomsandsignsandmaynotnecessarilywarrantlaboratorytesting,althoughdifferentiationfromotherillnesseswithsimilarclinical
manifestations(eg,dengue,chikungunya)maybedifficult[113,114].
Fornonpregnantpatientsresidinginareaswheremosquitotransmissionhasnotbeenestablishedandlaboratorytestingisavailable,diagnostictesting
iswarrantedforindividualswithcharacteristicsymptomsandsignsandrelevantepidemiologicexposure.(See'Symptomaticadults'below.)
Theapproachtodiagnosticevaluationofpregnantwomenandinfantswithintrauterineorintrapartuminfectionisdiscussedseparately.(See"Zikavirus
infection:Evaluationandmanagementofpregnantwomen".)
PatientgroupsIssuesrelatedtodiagnosisofZikavirusinfectioninsymptomaticadults(pregnantandnonpregnant)andsymptomaticchildrenwith
postnatalinfectionarediscussedbelow.ThereisnoroleforZikavirustestinginasymptomaticpatientswhoarenotpregnant.
IssuesrelatedtodiagnosisofZikavirusinfectioninasymptomaticpregnantwomenandinfantswithpossiblecongenitalZikavirusexposureare
discussedseparately.(See"Zikavirusinfection:Evaluationandmanagementofpregnantwomen".)
SymptomaticadultsThediagnosisofZikavirusinfectionisdefinitivelyestablishedviarealtimereversetranscriptionpolymerasechainreaction
(rRTPCR)forZikaviralRNA(inserumorurine)orZikavirusserology[33,84,112,115118]:
7/28
29/9/2016
Forindividualspresenting7daysafteronsetofsymptoms,diagnostictestingforZikavirusinfectionshouldincluderRTPCRofserumandurine
fordetectionofZikavirusRNA.rRTPCRtestingfordenguevirusandchikungunyavirusshouldalsobepursued.
SerumrRTPCRispositiveonlyforabriefwindow(threetosevendays)whentheinfectedpersonhasviremiatherefore,negativeresultscannot
excludeinfection.UrinerRTPCRmaybepositiveforupto14daysfollowingonsetofsymptoms.
Forindividualspresenting4to7daysafteronsetofsymptomswithnegativeZikavirusrRTPCR,Zikavirusserologictestingshouldbeperformed.
IfZikavirusIgMtestsresultsarepositive,equivocal,orinconclusive,testingforneutralizationantibodiesviaPRNTshouldbeperformedto
determinewhethertheZikavirusIgMreflectsrecentZikavirusinfectionorafalsepositiveresult.APRNTtitergreaterthan10shouldbe
interpretedasevidenceofinfectionwithaspecificflaviviruswhenthePRNTtotheothervirusestestedislessthan10(table2)[112].(See'Case
definitions'above.)
Testingfordenguevirusinfectionandchikungunyavirusinfectionshouldalsobepursued.AsinglelaboratoryPCRtestisavailablethroughthe
CDCandotherqualifiedlaboratoriestoevaluateforpresenceofZika,chikungunya,ordengueinfection[119].
Allserologicresultsshouldbeinterpretedwithcautionsincetherecanbecrossreactivitywithotherflaviviruses(includingdenguevirusandWest
Nilevirus).CrossreactivitymayalsobeobservedinindividualswhohavebeenvaccinatedagainstyellowfeverorJapaneseencephalitis[120].
Issuesrelatedtodiagnosisofdenguevirusandchikungunyavirusarediscussedseparately.(See"Clinicalmanifestationsanddiagnosisofdengue
virusinfection"and"Chikungunyafever",sectionon'Diagnosis'.)
Forindividualspresenting8to14daysaftertheonsetofsymptoms,diagnostictestingforZikavirusinfectionshouldincludeurinerRTPCRfor
detectionofZikavirusRNAaswellasZikavirusserologictesting(ZikavirusIgMandPRNT).
Forindividualspresenting15daysto12weeksafteronsetofsymptoms,diagnostictestingforZikavirusinfectionshouldconsistofZikavirus
serologictesting(ZikavirusIgMandPRNT).
Forindividualspresentingmorethan12weeksafteronsetofsymptoms,thereisnoroleforZikavirusserologictesting.
LaboratorytestingforZikavirusinfectionisperformedbythePanAmericanHealthOrganization/WHO,theCDCArboviralDiagnosticLaboratory,and
somestatehealthdepartments.IntheUnitedStates,statehealthdepartmentsshouldbecontactedtofacilitatediagnostictestingforZikavirus
infection.LaboratoryspecimensmayalsobesenttotheCDCArboviralDiagnosticLaboratoryinstructionsareavailableonline.Communicationshould
beinitiatedwiththelaboratoryviatelephone(19702216400)priortoshipmentofspecimens.
TheUnitedStatesFoodandDrugAdministrationhasalsoauthorizeduseofcommercialZikavirusserumPCRtestingandserologictestingbyqualified
laboratories[121,122].AsofAugust2016,commerciallaboratoriesperformingrRTPCRdonotperformZikaIgMenzymelinkedimmunosorbentassay
(ELISA)orconfirmatoryserologictesting(PRNT)[123].Therefore,ifpossible,providersshouldstoreaserumaliquotinarefrigerator(2to8C)for
subsequentZikaIgMELISAtestingiftherRTPCRassayisnegativeotherwise,collectionofanadditionalserumsamplemaybenecessary.
SymptomaticchildrenwithpostnatalinfectionPostnatalZikavirusinfection(eg,transmittedviamosquitobites)shouldbesuspectedinan
infantorchild<18yearswithrelevantepidemiologicexposureinthelasttwoweeksand2ofthefollowingmanifestations:fever,rash,conjunctivitis,or
8/28
29/9/2016
arthralgia[94].(See'Children'above.)
Thediagnosticapproachforthesechildrenisthesameasforadults,asdescribedabove.(See'Symptomaticadults'above.)
MANAGEMENTThereisnospecifictreatmentforZikavirusinfection.Managementconsistsofrestandsymptomatictreatment,includingdrinking
fluidstopreventdehydrationandadministrationofacetaminophentorelievefeverandpain[124].
Aspirinandothernonsteroidalantiinflammatorydrugs(NSAIDS)shouldbeavoideduntildengueinfectionhasbeenruledout,toreducetheriskof
hemorrhage.AspirinshouldnotbeusedinchildrenwithacuteviralillnessbecauseofitsassociationwithReyesyndrome.(See"Acutetoxicmetabolic
encephalopathyinchildren",sectionon'Reyesyndrome'.)
TheWorldHealthOrganizationhasissuedinitialguidanceonpsychosocialsupportforpatientsandfamiliesaffectedbyZikavirusinfectionand
associatedcomplications[125].
PREVENTIONThereisnovaccineforpreventionofZikavirusinfection.Modesoftransmissionaredescribedabove.(See'Transmission'above.)
Preventivemeasuresforpregnantandlactatingwomenandwomenofchildbearingpotentialarediscussedseparately.(See"Zikavirusinfection:
Evaluationandmanagementofpregnantwomen",sectionon'Prevention'.)
MosquitoprotectionIndividualsinareaswithriskfortransmissionshouldtakemeasurestoavoidmosquitobites,includingpersonalprotectionas
wellasenvironmentalcontrolmeasures[56].Aedesmosquitoesbiteduringthedaytimeaswellasattwilighttheybreedinstandingwater(particularly
manmadecontainers)[126].
Personalprotectivemeasuresinclude[56,127,128]:
Preventingmosquitobitesbywearinglongsleevesandlongpants,usinginsectrepellent,andstayingindoorsasfeasible(withairconditioning,
window/doorscreens,and/ormosquitonetstominimizecontactbetweenmosquitoesandpeople).(See"Preventionofarthropodandinsectbites:
Repellentsandothermeasures".)
IndividualswithZikavirusinfectionmayreducespreadofinfectiontoothersbyfollowingthesameprecautionstoavoidmosquitobitesduringthe
firstweekofillness(thelikelywindowofviremia).
AsymptomaticindividualswhohavetraveledtoanareawithZikavirusmosquitotransmissionandthenreturntoanareawithnoZikavirus
mosquitotransmissionshouldavoidmosquitobitesforthreeweeksafterreturn(theperiodduringwhichtheycouldbecomeviremic).
Environmentalcontrolmeasuresincludeidentificationandeliminationofpotentialmosquitobreedingsites.Mosquitolarvaebreedinstandingwater
therefore,residentsshouldbeinstructedtoavoidallowingstandingwatertocollectoutdoors(suchasinflowerpots,buckets,bottles,jars,andother
similarcontainersnearhouses).Domesticwatertanksshouldbecoveredsothatmosquitoescannotenter,anddrainsthatallowstagnantorstanding
watershouldbeeliminated.Localanddistricthealthdepartmentscanhelpfacilitatemitigationoftransmissionrisk.(See"Malariainendemicareas:
Epidemiology,prevention,andcontrol",sectionon'Mosquitocontrol'.)
9/28
29/9/2016
SexualtransmissionSexualtransmissionhasbeendescribedthedurationofviralpersistenceinsemenandinfemalegenitaltractsecretionsmay
beprolonged.(See'Transmission'above.)
Inallareas,menorwomenwithZikavirusinfectionorexposure(viatraveltomosquitotransmissionareasorsexualcontact)whohaveapregnant
partnershouldabstainfromunprotectedsexforthedurationofthepregnancy[50].(See"Malecondoms"and"Femalecondoms".)
WithinareasofZikavirusmosquitotransmission,itisprudentforindividualstoabstainfromsexualactivity(vaginal,anal,andoralsex)orusebarrier
protectionwhileactivetransmissionpersists[129].
OutsideareasofZikavirusmosquitotransmission,weareinagreementwithguidanceissuedbytheUnitedStatesCentersforDiseaseControland
Prevention(CDC)forcouplesinwhichoneorbothpartnershaveZikavirusinfectionorexposure,whichincludethefollowing[50,130]:
MenwithsymptomaticZikavirusinfection(confirmedorsuspected)shouldwaitatleastsixmonthsafteronsetofillnessbeforeunprotectedsex.
WomenwithsymptomaticZikavirusinfection(confirmedorsuspected)shouldwaitatleasteightweeksafteronsetofillnessbeforeunprotected
sex.
AsymptomaticmenandwomenwithZikavirusexposureshouldwaitatleasteightweeksafterZikavirusexposurebeforeunprotectedsex.
ThisguidancedifferssomewhatfromthatoftheWorldHealthOrganization(WHO),whichsuggeststhatmenandwomenoutsideareasofZika
transmissionwhohavetraveledtoareaswithactivetransmissionwaitatleastsixmonthsfollowingtheirreturnbeforeunprotectedsex,regardlessof
symptoms[131].TheWHOindicatesthatthisisaconservativerecommendation,basedinpartonthelimiteddataonthedurationandinfectivityofZika
virusinthesemenfollowinginitialinfection.(See'Transmission'above.)
IssuesrelatedtopreventionofZikavirusduringpregnancyarediscussedfurtherseparately.(See"Zikavirusinfection:Evaluationandmanagementof
pregnantwomen",sectionon'Prevention'.)
Blood/tissuedonationZikavirusistransmissibleviabloodproductsandorganortissuetransplantation[24,48].Issuesrelatedtodonorscreening
arediscussedfurtherseparately.(See"Blooddonorscreening:Medicalhistory",sectionon'Zikavirus'and"Blooddonorscreening:Laboratory
testing".)
TheUSFoodandDrugAdministration(FDA)hasissueddonordeferralrecommendationsforhematopoieticstemcells,tissues,anddonorgametes
therecommendationsdonotapplytosolidorgans[132].LivingdonorswithZikavirusinfectionorrelevantepidemiologicexposure(residenceinor
traveltoanareawheremosquitobornetransmissionofZikavirusinfectionhasbeenreported,orunprotectedsexualcontactwithapersonwhomeets
thesecriteria)shouldbeconsideredineligiblefordonationforsixmonths.DeceaseddonorswithZikavirusinfectionintheprecedingsixmonthsshould
bealsobeconsideredineligible.
NosocomialtransmissionTransmissionofZikavirusviaoccupationalexposureinahealthcaresettinghasnotbeendescribed.Standard
precautionsareappropriateforprotectionofhealthcarepersonnelandpatientsfromZikavirusinfectioninthesesettings[129,133].(See"General
principlesofinfectioncontrol",sectionon'Standardprecautions'.)
10/28
29/9/2016
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and"BeyondtheBasics."TheBasics
patienteducationpiecesarewritteninplainlanguage,atthe5thto6thgradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatient
mighthaveaboutagivencondition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.
BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10thto12thgrade
readinglevelandarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopicstoyourpatients.(Youcanalso
locatepatienteducationarticlesonavarietyofsubjectsbysearchingon"patientinfo"andthekeyword(s)ofinterest.)
Basicstopics(see"Patienteducation:Zikavirusinfection(TheBasics)"and"Patienteducation:GuillainBarrsyndrome(TheBasics)")
SUMMARY
OutbreaksofZikavirusinfection,causedbyanemergingmosquitoborneflavivirus,haveoccurredinAfrica,SoutheastAsia,andthePacific
Islandscurrently,thereisanongoingZikavirusoutbreakintheAmericas.ZikavirusistransmittedtohumansviathebiteofaninfectedAedes
mosquito.Thistypeofmosquitousuallybitesduringthedaytimeandbreedsinstandingwater(particularlymanmadecontainers).(See
'Epidemiology'above.)
ClinicalmanifestationsofZikavirusinfectionincludeacuteonsetoflowgradefeverwithmaculopapularpruriticrash,arthralgia(notablysmalljoints
ofhandsandfeet),orconjunctivitis(nonpurulent)clinicalillnessisconsistentwithZikavirusdiseaseiftwoormoreofthesesymptomsarepresent.
Zikavirusinfectionhasalsobeenassociatedwithcongenitalmicrocephaly,fetalloss,andGuillainBarrsyndrome.(See'Clinicalmanifestations'
above.)
Theincubationperiodbetweenmosquitobiteandonsetofclinicalmanifestationsistypically2to14days.Theillnessisusuallymildclinical
manifestationsusuallyresolvewithintwotosevendays.Asymptomaticinfectioniscommonsymptomsdevelopin20to25percentofindividuals
whobecomeinfectedwithZikavirus.Onceapersonhasbeeninfected,heorsheislikelytobeprotectedfromfutureinfections.(See'Symptoms
andsigns'above.)
ThediagnosisofZikavirusinfectionshouldbesuspectedinindividualswithtypicalclinicalmanifestationsandrelevantepidemiologicexposure
(residenceinortraveltoanareawheremosquitobornetransmissionofZikavirusinfectionhasbeenreported,orunprotectedsexualcontactwith
apersonwhomeetsthesecriteria).(See'Diagnosis'above.)
ThediagnosisofZikavirusinfectionisestablishedviarealtimereversetranscriptionpolymerasechainreaction(rRTPCR)testingforZikaviral
RNA(inserumorurine)orserology.Theapproachtodiagnostictestingdependsonthetimingofpresentationafteronsetofsymptoms.(See
'Patientgroups'above.)
ThereisnospecifictreatmentforZikavirusinfectionandthereisnovaccineforprevention.Managementconsistsofsymptomatictreatment.
Preventivemeasuresincludepersonalprotectivemeasurestopreventmosquitobitesandinstitutionofmeasurestoeliminateandcontrolmosquito
breedingsites.(See'Management'aboveand'Mosquitoprotection'above.)
11/28
29/9/2016
SexualtransmissionofZikavirushasbeendescribed.Inallareas,menorwomenwithZikavirusinfectionorexposure(viatraveltomosquito
transmissionareasorsexualcontact)whohaveapregnantpartnershouldabstainfromunprotectedsexforthedurationofthepregnancy.Within
areasofZikavirusmosquitotransmission,itisprudentforindividualstoabstainfromsexualactivity(vaginal,anal,andoralsex)orusebarrier
protectionwhileactivetransmissionpersists.(See'Sexualtransmission'above.)
OutsideareasofZikavirusmosquitotransmission,guidanceforcouplesinwhichoneorbothpartnershaveZikavirusinfectionorexposure
includethefollowing(see'Sexualtransmission'above):
MenwithsymptomaticZikavirusinfection(confirmedorsuspected)shouldwaitatleastsixmonthsafteronsetofillnessbeforeunprotected
sex.
WomenwithsymptomaticZikavirusinfection(confirmedorsuspected)shouldwaitatleasteightweeksafteronsetofillnessbefore
unprotectedsex.
AsymptomaticmenandwomenwithZikavirusexposureshouldwaitatleasteightweeksafterZikavirusexposurebeforeunprotectedsex.
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1.PetersenLR,JamiesonDJ,PowersAM,HoneinMA.ZikaVirus.NEnglJMed2016374:1552.
2.MussoD,GublerDJ.ZikaVirus.ClinMicrobiolRev201629:487.
3.AndersonKB,ThomasSJ,EndyTP.TheEmergenceofZikaVirus:ANarrativeReview.AnnInternMed2016165:175.
4.FocosiD,MaggiF,PistelloM.ZikaVirus:ImplicationsforPublicHealth.ClinInfectDis201663:227.
5.TangH,HammackC,OgdenSC,etal.ZikaVirusInfectsHumanCorticalNeuralProgenitorsandAttenuatesTheirGrowth.CellStemCell2016
18:587.
6.MlakarJ,KorvaM,TulN,etal.ZikaVirusAssociatedwithMicrocephaly.NEnglJMed2016374:951.
7.NowakowskiTJ,PollenAA,DiLulloE,etal.ExpressionAnalysisHighlightsAXLasaCandidateZikaVirusEntryReceptorinNeuralStemCells.
CellStemCell201618:591.
8.SirohiD,ChenZ,SunL,etal.The3.8resolutioncryoEMstructureofZikavirus.Science2016352:467.
9.GarcezPP,LoiolaEC,MadeirodaCostaR,etal.Zikavirusimpairsgrowthinhumanneurospheresandbrainorganoids.Science2016352:816.
10.WorldHealthOrganization.Emergencies:Zikasituationreport.http://www.who.int/emergencies/zikavirus/situationreport/31march2016/en/
(AccessedonApril01,2016).
12/28
29/9/2016
11.WorldHealthOrganization.ConsensusoncausallinkbetweenZikaandneurologicaldisorders.http://www.euro.who.int/en/health
topics/emergencies/zikavirus/news/news/2016/04/consensusoncausallinkbetweenzikaandneurologicaldisorders(AccessedonApril11,
2016).
12.WorldHealthOrganization.Zikasituationreport.http://www.who.int/emergencies/zikavirus/situationreport/7april2016/en/(AccessedonApril
18,2016).
13.WorldHealthOrganization.WHODirectorGeneralbriefsExecutiveBoardonZikasituation.http://www.who.int/dg/speeches/2016/zika
situation/en/(AccessedonJanuary31,2016).
14.WorldHealthOrganization.WHODirectorGeneralsummarizestheoutcomeoftheEmergencyCommitteeonZika.
http://www.who.int/mediacentre/news/statements/2016/emergencycommitteezikamicrocephaly/en/(AccessedonFebruary01,2016).
15.FauciAS,MorensDM.ZikaVirusintheAmericasYetAnotherArbovirusThreat.NEnglJMed2016374:601.
16.HennesseyM,FischerM,StaplesJE.ZikaVirusSpreadstoNewAreasRegionoftheAmericas,May2015January2016.MMWRMorbMortal
WklyRep201665:55.
17.ChenLH,HamerDH.ZikaVirus:RapidSpreadintheWesternHemisphere.AnnInternMed2016164:613.
18.WorldHealthOrganization.Emergencies:ThehistoryofZikavirus.http://www.who.int/emergencies/zikavirus/timeline/en/(AccessedonFebruary
25,2016).
19.LanciottiRS,KosoyOL,LavenJJ,etal.GeneticandserologicpropertiesofZikavirusassociatedwithanepidemic,YapState,Micronesia,2007.
EmergInfectDis200814:1232.
20.DuffyMR,ChenTH,HancockWT,etal.ZikavirusoutbreakonYapIsland,FederatedStatesofMicronesia.NEnglJMed2009360:2536.
21.HayesEB.ZikavirusoutsideAfrica.EmergInfectDis200915:1347.
22.DyerO.ZikavirusspreadsacrossAmericasasconcernsmountoverbirthdefects.BMJ2015351:h6983.
23.CauchemezS,BesnardM,BompardP,etal.AssociationbetweenZikavirusandmicrocephalyinFrenchPolynesia,201315:aretrospective
study.Lancet2016387:2125.
24.MussoD,NhanT,RobinE,etal.PotentialforZikavirustransmissionthroughbloodtransfusiondemonstratedduringanoutbreakinFrench
Polynesia,November2013toFebruary2014.EuroSurveill201419.
25.GathererD,KohlA.Zikavirus:apreviouslyslowpandemicspreadsrapidlythroughtheAmericas.JGenVirol201697:269.
26.FariaNR,AzevedoRdoS,KraemerMU,etal.ZikavirusintheAmericas:Earlyepidemiologicalandgeneticfindings.Science2016352:345.
27.MeaneyDelmanD,HillsSL,WilliamsC,etal.ZikaVirusInfectionAmongU.S.PregnantTravelersAugust2015February2016.MMWRMorb
MortalWklyRep201665:211.
28.CentersforDiseaseControlandPrevention.ZikavirusdiseaseintheUnitedStates,20152016.http://www.cdc.gov/zika/geo/unitedstates.html
(AccessedonMarch21,2016).
13/28
29/9/2016
29.ArmstrongP,HennesseyM,AdamsM,etal.TravelAssociatedZikaVirusDiseaseCasesAmongU.S.ResidentsUnitedStates,January2015
February2016.MMWRMorbMortalWklyRep201665:286.
30.LeeCT,VoraNM,BajwaW,etal.ZikaVirusSurveillanceandPreparednessNewYorkCity,20152016.MMWRMorbMortalWklyRep2016
65:629.
31.StateofHawaii.DOHNewsRelease:HawaiiDepartmentofHealthReceivesConfirmationofZikaInfectioninBabyBornwithMicrocephaly.
http://governor.hawaii.gov/newsroom/dohnewsreleasehawaiidepartmentofhealthreceivesconfirmationofzikainfectioninbabybornwith
microcephaly/(AccessedonJanuary27,2016).
32.DallasCountyHealthandHumanServices.DCHHSReportsFirstZikaVirusCaseinDallasCountyAcquiredThroughSexualTransmission.
http://www.dallascounty.org/department/hhs/press/documents/PR2216DCHHSReportsFirstCaseofZikaVirusThroughSexualTransmission.pdf
(AccessedonFebruary03,2016).
33.CentersforDiseaseControlandPrevention.EmergencyPreparednessandResponse:Recognizing,Managing,andReportingZikaVirus
InfectionsinTravelersReturningfromCentralAmerica,SouthAmerica,theCaribbean,andMexico.http://emergency.cdc.gov/han/han00385.asp
(AccessedonJanuary18,2016).
34.CentersforDiseaseControlandPrevention.CDCNewsroom:CDCaddscountriestointerimtravelguidancerelatedtoZikavirus.
http://www.cdc.gov/media/releases/2016/s0122zikatravelguidance.html(AccessedonJanuary25,2016).
35.EuropeanCentreforDiseasePreventionandControl.RapidRiskAssessment:Zikavirusdiseaseepidemic:Potentialassociationwith
microcephalyandGuillainBarresyndrome(firstupdate),21January2016.ECDC,Stockholm2016.
http://ecdc.europa.eu/en/publications/Publications/rapidriskassessmentzikavirusfirstupdatejan2016.pdf(AccessedonJanuary26,2016).
36.WorldHealthOrganization.WHOstatementonthe2ndmeetingofIHREmergencyCommitteeonZikavirusandobservedincreasein
neurologicaldisordersandneonatalmalformations.http://www.who.int/mediacentre/news/statements/2016/2ndemergencycommitteezika/en/
(AccessedonMarch09,2016).
37.CentersforDiseaseControlandPrevention.CDCissuesadvicefortraveltothe2016SummerOlympicGames.
http://www.cdc.gov/media/releases/2016/s0226summerolympicgames.html(AccessedonFebruary29,2016).
38.CetronM.RevisiontoCDC'sZikaTravelNotices:MinimalLikelihoodforMosquitoBorneZikaVirusTransmissionatElevationsAbove2,000
Meters.MMWRMorbMortalWklyRep201665:267.
39.PanAmericanHealthOrganization.ZikaVirusInfection.http://www.paho.org/hq/index.php?
option=com_topics&view=article&id=427&Itemid=41484(AccessedonJanuary18,2016).
40.CentersforDiseaseControlandPrevention.Travelers'Health:TravelHealthNotices.http://wwwnc.cdc.gov/travel/notices(AccessedonAugust
31,2016).
41.CentersforDiseaseControlandPrevention.AdviceforpeoplelivinginortravelingtoSouthFlorida.http://www.cdc.gov/zika/intheus/florida
update.html(AccessedonAugust22,2016).
14/28
29/9/2016
42.LikosA,GriffinI,BinghamAM,etal.LocalmosquitobornetransmissionofZikavirusMiamiDadeandBrowardCounties,Florida,June
August2016.MMWRMorbMortalWklyRep201665.
43.ThomasDL,SharpTM,TorresJ,etal.LocalTransmissionofZikaVirusPuertoRico,November23,2015January28,2016.MMWRMorb
44.AdamsL,BelloPaganM,LozierM,etal.Update:OngoingZikaVirusTransmissionPuertoRico,November1,2015July7,2016.MMWRMorb
45.CentersforDiseaseControlandPrevention.CDCencouragesfollowingguidancetopreventsexualtransmissionofZikavirus.
http://www.cdc.gov/media/releases/2016/s0223zikaguidance.html(AccessedonFebruary24,2016).
46.CentersforDiseaseControlandPrevention.CDCHealthAlertNetwork(HAN)HealthAdvisoryRegardingInterimGuidelinesforPreventionof
SexualTransmissionofZikaVirusUnitedStates,2016.http://content.govdelivery.com/accounts/USCDC/bulletins/1383171(Accessedon
February24,2016).
47.VenturiG,ZammarchiL,FortunaC,etal.AnautochthonouscaseofZikaduetopossiblesexualtransmission,Florence,Italy,2014.EuroSurveill
201621.
48.CentersforDiseaseControlandPrevention.Zikavirus:Transmission.http://www.cdc.gov/zika/transmission/index.html(AccessedonFebruary03,
2016).
49.DavidsonA,SlavinskiS,KomotoK,etal.SuspectedFemaletoMaleSexualTransmissionofZikaVirusNewYorkCity,2016.MMWRMorb
50.BrooksJT,FriedmanA,KachurRE,etal.Update:InterimGuidanceforPreventionofSexualTransmissionofZikaVirusUnitedStates,July
2016.MMWRMorbMortalWklyRep201665:745.
51.MottaIJ,SpencerBR,CordeirodaSilvaSG,etal.EvidenceforTransmissionofZikaVirusbyPlateletTransfusion.NEnglJMed2016.
52.CentersforDiseaseControlandPrevention.ZikaVirus:Transmission.http://www.cdc.gov/zika/transmission/index.html(AccessedonJanuary13,
2016).
53.CentersforDiseaseControlandPrevention.ChikungunyaVirus:SurveillanceandControlofAedesaegyptiandAedesalbopictusintheUnited
States.http://www.cdc.gov/chikungunya/resources/vectorcontrol.html(AccessedonJanuary18,2016).
54.BogochII,BradyOJ,KraemerMU,etal.AnticipatingtheinternationalspreadofZikavirusfromBrazil.Lancet2016387:335.
55.MonaghanAJ,MorinCW,SteinhoffDF,etal.OntheSeasonalOccurrenceandAbundanceoftheZikaVirusVectorMosquitoAedesAegyptiin
theContiguousUnitedStates.PLoSCurr20168.
56.PanAmericanHealthOrganization.ZikavirusinfectionandZikafever:Frequentlyaskedquestions.http://www.paho.org/hq/index.php?
option=com_content&view=article&id=9183&Itemid=41463&lang=en(AccessedonJanuary13,2016).
57.GourinatAC,O'ConnorO,CalvezE,etal.DetectionofZikavirusinurine.EmergInfectDis201521:84.
58.MussoD,RocheC,NhanTX,etal.DetectionofZikavirusinsaliva.JClinVirol201568:53.
15/28
29/9/2016
59.DupontRouzeyrolM,BironA,O'ConnorO,etal.InfectiousZikaviralparticlesinbreastmilk.Lancet2016387:1051.
60.RozB,NajioullahF,FergJL,etal.ZikavirusdetectioninurinefrompatientswithGuillainBarrsyndromeonMartinique,January2016.Euro
Surveill201621.
61.BarzonL,PacentiM,BertoA,etal.IsolationofinfectiousZikavirusfromsalivaandprolongedviralRNAsheddinginatravellerreturningfromthe
DominicanRepublictoItaly,January2016.EuroSurveill201621.
62.PrisantN,BujanL,BenichouH,etal.Zikavirusinthefemalegenitaltract.LancetInfectDis2016.
63.LustigY,MendelsonE,ParanN,etal.DetectionofZikavirusRNAinwholebloodofimportedZikavirusdiseasecasesupto2monthsafter
symptomonset,Israel,December2015toApril2016.EuroSurveill201621.
64.DriggersRW,HoCY,KorhonenEM,etal.ZikaVirusInfectionwithProlongedMaternalViremiaandFetalBrainAbnormalities.NEnglJMed
2016374:2142.
65.CamposRdeM,CirneSantosC,MeiraGL,etal.ProlongeddetectionofZikavirusRNAinurinesamplesduringtheongoingZikavirusepidemic
inBrazil.JClinVirol201677:69.
66.BinghamAM,ConeM,MockV,etal.ComparisonofTestResultsforZikaVirusRNAinUrine,Serum,andSalivaSpecimensfromPersonswith
TravelAssociatedZikaVirusDiseaseFlorida,2016.MMWRMorbMortalWklyRep201665:475.
67.NicastriE,CastillettiC,LiuzziG,etal.PersistentdetectionofZikavirusRNAinsemenforsixmonthsaftersymptomonsetinatravellerreturning
fromHaititoItaly,February2016.EuroSurveill201621.
68.BonaldoMC,RibeiroIP,LimaNS,etal.IsolationofInfectiveZikaVirusfromUrineandSalivaofPatientsinBrazil.PLoSNeglTropDis2016
10:e0004816.
69.AtkinsonB,HearnP,AfroughB,etal.DetectionofZikaVirusinSemen.EmergInfectDis201622:940.
70.MansuyJM,PasquierC,DaudinM,etal.Zikavirusinsemenofapatientreturningfromanonepidemicarea.LancetInfectDis201616:894.
71.HarrowerJ,KiedrzynskiT,BakerS,etal.SexualTransmissionofZikaVirusandPersistenceinSemen,NewZealand,2016.EmergInfectDis
201622.
72.JangHC,ParkWB,KimUJ,etal.FirstImportedCaseofZikaVirusInfectionintoKorea.JKoreanMedSci201631:1173.
73.TurmelJM,AbgueguenP,HubertB,etal.LatesexualtransmissionofZikavirusrelatedtopersistenceinthesemen.Lancet2016387:2501.
74.MansuyJM,DutertreM,MengelleC,etal.Zikavirus:highinfectiousviralloadinsemen,anewsexuallytransmittedpathogen?LancetInfectDis
201616:405.
75.BrooksRB,CarlosMP,MyersRA,etal.LikelySexualTransmissionofZikaVirusfromaManwithNoSymptomsofInfectionMaryland,2016.
MMWRMorbMortalWklyRep201665:915.
76.BrentC,DunnA,SavageH,etal.PreliminaryFindingsfromanInvestigationofZikaVirusInfectioninaPatientwithNoKnownRiskFactors
Utah,2016.MMWRMorbMortalWklyRep201665:981.
16/28
29/9/2016
77.WorldHealthOrganization.ZikavirusandtheOlympicandParalympicGamesRio2016.
http://www.who.int/mediacentre/news/statements/2016/zikaolympics/en/(AccessedonMay16,2016).
78.CentersforDiseaseControlandPrevention.ZikaVirusDiseaseQ&A.http://www.cdc.gov/zika/diseaseqa.html(AccessedonFebruary03,
2016).
79.CentersforDiseaseControlandPrevention.ZikaVirus:ForHealthCareProviders:ClinicalEvaluation&Disease.http://www.cdc.gov/zika/hc
providers/clinicalevaluation.html(AccessedonJanuary13,2016).
80.ArzuzaOrtegaL,PoloA,PrezTatisG,etal.FatalSickleCellDiseaseandZikaVirusInfectioninGirlfromColombia.EmergInfectDis2016
22:925.
81.BaudD,VanMieghemT,MussoD,etal.ClinicalmanagementofpregnantwomenexposedtoZikavirus.LancetInfectDis201616:523.
82.DirlikovE,RyffKR,TorresAponteJ,etal.Update:OngoingZikaVirusTransmissionPuertoRico,November1,2015April14,2016.MMWR
MorbMortalWklyRep201665:451.
83.SarmientoOspinaA,VsquezSernaH,JimenezCanizalesCE,etal.ZikavirusassociateddeathsinColombia.LancetInfectDis201616:523.
84.PetersenEE,StaplesJE,MeaneyDelmanD,etal.InterimGuidelinesforPregnantWomenDuringaZikaVirusOutbreakUnitedStates,2016.
MMWRMorbMortalWklyRep201665:30.
85.ChenLH.ZikaVirusInfectioninaMassachusettsResidentAfterTraveltoCostaRica:ACaseReport.AnnInternMed2016164:574.
86.BrasilP,CalvetGA,SiqueiraAM,etal.ZikaVirusOutbreakinRiodeJaneiro,Brazil:ClinicalCharacterization,EpidemiologicalandVirological
Aspects.PLoSNeglTropDis201610:e0004636.
87.MinistryofHealthManuatuHauora.Zikavirus.http://www.health.govt.nz/ourwork/diseasesandconditions/zikavirus(AccessedonJanuary13,
2016).
88.ZammarchiL,StellaG,MantellaA,etal.ZikavirusinfectionsimportedtoItaly:clinical,immunologicalandvirologicalfindings,andpublichealth
implications.JClinVirol201563:32.
89.KarimiO,GoorhuisA,SchinkelJ,etal.ThrombocytopeniaandsubcutaneousbleedingsinapatientwithZikavirusinfection.Lancet2016
387:939.
90.DerringtonSM,CelluraAP,McDermottLE,etal.MucocutaneousFindingsandCourseinanAdultWithZikaVirusInfection.JAMADermatol
2016152:691.
91.FurtadoJM,EspsitoDL,KleinTM,etal.UveitisAssociatedwithZikaVirusInfection.NEnglJMed2016375:394.
92.SharpTM,MuozJordnJ,PerezPadillaJ,etal.ZikaVirusInfectionAssociatedWithSevereThrombocytopenia.ClinInfectDis2016.
93.DasguptaS,ReaganSteinerS,GoodenoughD,etal.PatternsinZikaVirusTestingandInfection,byReportofSymptomsandPregnancyStatus
UnitedStates,January3March5,2016.MMWRMorbMortalWklyRep201665:395.
94.FlemingDutraKE,NelsonJM,FischerM,etal.Update:InterimGuidelinesforHealthCareProvidersCaringforInfantsandChildrenwith
PossibleZikaVirusInfectionUnitedStates,February2016.MMWRMorbMortalWklyRep201665:182.
17/28
29/9/2016
95.CentersforDiseaseControlandPrevention.QuestionandAnswers:Zikavirusinfection(Zika)andpregnancy.
http://www.cdc.gov/zika/pregnancy/questionanswers.html(AccessedonFebruary05,2016).
96.KarwowskiMP,NelsonJM,StaplesJE,etal.ZikaVirusDisease:ACDCUpdateforPediatricHealthCareProviders.Pediatrics2016137.
97.EuropeanCentreforDiseasePreventionandControl.RapidRiskAssessment:Zikavirusdiseaseepidemic:Potentialassociationwith
microcephalyandGuillainBarresyndrome(firstupdate),21January2016.ECDC,Stockholm2016.
http://ecdc.europa.eu/en/publications/Publications/rapidriskassessmentzikavirusfirstupdatejan2016.pdf(AccessedonJanuary25,2016).
98.PanAmericanHealthOrganization/WorldHealthOrganization.Epidemiologicupdate:Neurologicalsyndrome,congenitalanomalies,andZika
virusinfection,17January2016.PAHO/WHO,Washington,DC2016.http://www.paho.org/hq/index.php?
option=com_docman&task=doc_view&Itemid=270&gid=32879&lang=en(AccessedonJanuary25,2016).
99.DirlikovE,MajorCG,MayshackM,etal.GuillainBarrSyndromeDuringOngoingZikaVirusTransmissionPuertoRico,January1July31,
2016.MMWRMorbMortalWklyRep201665:910.
100.DosSantosT,RodriguezA,AlmironM,etal.ZikaVirusandtheGuillainBarrSyndromeCaseSeriesfromSevenCountries.NEnglJMed
2016.
101.EuropeanCentreforDiseasePreventionandControl.RapidRiskAssessment:ZikavirusepidemicintheAmericas:Potentialassociationswith
microcephalyandGuillainBarresyndrome.http://ecdc.europa.eu/en/publications/Publications/zikavirusamericasassociationwithmicrocephaly
rapidriskassessment.pdf(AccessedonJanuary13,2016).
102.PanAmericanHealthOrganization.EpidemiologicalAlert:Neurologicalsyndrome,congenitalmalformations,andZikavirusinfection.Implications
forpublichealthintheAmericas,1December2015.http://www.paho.org/hq/index.php?
option=com_docman&task=doc_view&Itemid=270&gid=32405&lang=en(AccessedonJanuary13,2016).
103.OehlerE,WatrinL,LarreP,etal.ZikavirusinfectioncomplicatedbyGuillainBarresyndromecasereport,FrenchPolynesia,December2013.
EuroSurveill201419.
104.WorldHealthOrganization.GuillainBarrsyndromeFranceFrenchPolynesia.http://www.who.int/csr/don/7march2016gbsfrench
polynesia/en/(AccessedonMarch09,2016).
105.CaoLormeauVM,BlakeA,MonsS,etal.GuillainBarrSyndromeoutbreakassociatedwithZikavirusinfectioninFrenchPolynesia:acase
controlstudy.Lancet2016387:1531.
106.PaploskiIA,PratesAP,CardosoCW,etal.TimeLagsbetweenExanthematousIllnessAttributedtoZikaVirus,GuillainBarrSyndrome,and
Microcephaly,Salvador,Brazil.EmergInfectDis201622:1438.
107.McharlesS,HerrmannC,PoullainP,etal.AcutemyelitisduetoZikavirusinfection.Lancet2016387:1481.
108.CarteauxG,MaquartM,BedetA,etal.ZikaVirusAssociatedwithMeningoencephalitis.NEnglJMed2016374:1595.
109.RozB,NajioullahF,SignateA,etal.Zikavirusdetectionincerebrospinalfluidfromtwopatientswithencephalopathy,Martinique,February
2016.EuroSurveill201621.
18/28
29/9/2016
110.VillamilGmezWE,GonzlezCamargoO,RodriguezAyubiJ,etal.Dengue,chikungunyaandZikacoinfectioninapatientfromColombia.J
InfectPublicHealth20169:684.
111.WorldHealthOrganization.Emergenciespreparedness,response:Zikavirusdisease.http://www.who.int/csr/disease/zika/casedefinition/en/
(AccessedonFebruary16,2016).
112.RabeIB,StaplesJE,VillanuevaJ,etal.InterimGuidanceforInterpretationofZikaVirusAntibodyTestResults.MMWRMorbMortalWklyRep
201665:543.
113.PanAmericanHealthOrganization.ZikavirusinfectionandZikafever:Frequentlyaskedquestions.http://www.paho.org/hq/index.php?
option=com_content&view=article&id=9183%3A2015preguntasfrecuentesvirusfiebrezika&catid=3986%3Azikavirus
infection&Itemid=41463&lang=en(AccessedonJanuary28,2016).
114.WorldHealthOrganization.LaboratorytestingforZikavirusinfection:Interimguidance,23March2016.
http://apps.who.int/iris/bitstream/10665/204671/1/WHO_ZIKV_LAB_16.1_eng.pdf?ua=1(AccessedonMarch24,2016).
115.CentersforDiseaseControlandPrevention.ZikaVirus:ForHealthCareProviders:DiagnosticTesting.http://www.cdc.gov/zika/hc
providers/diagnostic.html(AccessedonJanuary13,2016).
116.PanAmericanHealthOrganization.ZikaVirusInfection.http://www.paho.org/hq/index.php?
option=com_topics&view=article&id=427&Itemid=41484&lang=en#(AccessedonJanuary13,2016).
117.OduyeboT,PetersenEE,RasmussenSA,etal.Update:InterimGuidelinesforHealthCareProvidersCaringforPregnantWomenandWomen
ofReproductiveAgewithPossibleZikaVirusExposureUnitedStates,2016.MMWRMorbMortalWklyRep201665:122.
118.InterimGuidanceforZikaVirusTestingofUrineUnitedStates,2016.MMWRMorbMortalWklyRep201665:474.
119.CentersforDiseaseControlandPrevention.NewCDCLaboratoryTestforZikaVirusAuthorizedforEmergencyUsebyFDA.
http://www.cdc.gov/media/releases/2016/s0318zikalabtest.html(AccessedonMarch21,2016).
120.CentersforDiseaseControlandPrevention.QuestionsandAnswersforObstetricalHealthcareProviders:PregnantWomenandZikaVirus
Infection.http://www.cdc.gov/zika/hcproviders/qapregnantwomen.html(AccessedonFebruary02,2016).
121.USFoodandDrugAdministration.EmergencyUseAuthorizations.
http://www.fda.gov/MedicalDevices/Safety/EmergencySituations/ucm161496.htm#zika(AccessedonMay02,2016).
122.USFoodandDrugAdministration.Zikadiagnosticupdate|Newcrossspeciesimmunesystemreference(openaccess!).
https://content.govdelivery.com/accounts/USFDA/bulletins/15da29b(AccessedonAugust22,2016).
123.CentersforDiseaseControlandPrevention.CDCHealthAlertNetwork(HAN)HealthUpdate:CDCRecommendationsforSubsequentZikaIgM
AntibodyTesting.https://content.govdelivery.com/accounts/USCDC/bulletins/150b812(AccessedonJune23,2016).
124.CentersforDiseaseControlandPrevention.ZikaVirus:Symptoms,Diagnosis,&Treatment.http://www.cdc.gov/zika/symptoms/index.html
(AccessedonJanuary13,2016).
125.WorldHealthOrganization.Emergenciespreparedness,response:Psychosocialsupportforpregnantwomenandforfamilieswithmicrocephaly
andotherneurologicalcomplicationsinthecontextofZikavirus:Interimguidanceforhealthcareproviders.
19/28
29/9/2016
http://who.int/csr/resources/publications/zika/psychosocialsupport/en/(AccessedonFebruary29,2016).
126.JansenCC,BeebeNW.ThedenguevectorAedesaegypti:whatcomesnext.MicrobesInfect201012:272.
127.CentersforDiseaseControlandPrevention.InterimGuidanceforProtectingWorkersfromOccupationalExposuretoZikaVirus.
http://www.cdc.gov/niosh/topics/outdoor/mosquitoborne/pdfs/oshaniosh_fs3855_zika_virus_042016.pdf#page=1(AccessedonApril25,2016).
128.CentersforDiseaseControlandPrevention.Zikavirus:Prevention.http://www.cdc.gov/zika/prevention/index.html(AccessedonJune08,2016).
129.MllerJA,HarmsM,SchubertA,etal.InactivationandEnvironmentalStabilityofZikaVirus.EmergInfectDis201622:1685.
130.PetersenEE,PolenKN,MeaneyDelmanD,etal.Update:InterimGuidanceforHealthCareProvidersCaringforWomenofReproductiveAge
withPossibleZikaVirusExposureUnitedStates,2016.MMWRMorbMortalWklyRep201665:315.
131.WorldHealthOrganization.PreventionofpotentialsexualtransmissionofZikavirus:Interimguidance,18February2016.
http://apps.who.int/iris/bitstream/10665/204421/1/WHO_ZIKV_MOC_16.1_eng.pdf?ua=1(AccessedonFebruary19,2016).
132.USFoodandDrugAdministration.DonorScreeningRecommendationstoReducetheRiskofTransmissionofZikaVirusbyHumanCells,
Tissues,andCellularandTissueBasedProducts:GuidanceforIndustry,March2016.
http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/Tissue/UCM488582.pdf(Accessed
onMarch07,2016).
133.OlsonCK,IwamotoM,PerkinsKM,etal.PreventingTransmissionofZikaVirusinLaborandDeliverySettingsThroughImplementationof
StandardPrecautionsUnitedStates,2016.MMWRMorbMortalWklyRep201665:290.
Topic106169Version108.0
20/28
29/9/2016
GRAPHICS
EstimatedrangeofAedesaegyptiandAedesalbopictusintheUnited
States
21/28
29/9/2016
22/28
29/9/2016
Thesemapsshowareaswheremosquitoesareorhavebeenpreviouslyfound(basedonavarietyof
sources)andreflectestimatesofthepotentialrangeofAedesaegyptiandAedesalbopictusintheUnited
States.Thesemapsdonotshowexactlocationsornumbersofmosquitoeslivinginanareanordothey
representriskforspreadofdisease.
Reproducedfrom:CentersforDiseaseControlandPrevention.ZikaVirus:VectorSurveillanceandControl.
Availableat:http://www.cdc.gov/zika/vector/index.html(AccessedonMarch31,2016).
Graphic106382Version3.0
23/28
29/9/2016
GlobaldistributionofAedesaegyptiandAedesalbopictus
From:MussoD,GublerDJ.Zikavirus.ClinMicrobiolRev201629(3):487524.DOI:10.1128/CMR.0007215.Reproducedwithpermissionfrom
AmericanSocietyforMicrobiology.Copyright2016.
24/28
29/9/2016
Clinicalfeatures:Zikaviruscomparedwithdengueandchikungunya
Features
Zika
Dengue
Chikungunya
Fever
++
+++
+++
Rash
+++
++
Conjunctivitis
++
Arthralgia
++
+++
Myalgia
++
Headache
++
++
Hemorrhage
++
Shock
Reproducedfrom:CentersforDiseaseControlandPrevention.ZikavirusWhatcliniciansneedtoknow?ClinicianOutreachandCommunicationActivity(COCA)Call,
January26,2016.Availableat:http://emergency.cdc.gov/coca/ppt/2016/01_26_16_zika.pdf(AccessedFebruary1,2016).
25/28
29/9/2016
InterpretationofresultsofantibodytestingforsuspectedZikavirusinfection* UnitedStates,2016
Zikavirusanddenguevirus
IgMELISA
ZikavirusPRNT
DenguevirusPRNT
Interpretation
Positiveorequivocal(eitherassay)
10
<10
RecentZikavirusinfection
<10
10
Recentdenguevirusinfection
10
10
Recentflavivirusinfectionspecific
viruscannotbeidentified
InconclusiveinoneassayAND
inconclusiveornegativeintheother
10
<10
EvidenceofZikavirusinfectiontiming
cannotbedetermined
<10
10
Evidenceofdenguevirusinfection
timingcannotbedetermined
10
10
Evidenceofflavivirusinfection
specificvirusandtimingcannotbe
determined
Anyresult(eitherorbothassays)
<10
<10
NoevidenceofZikavirusordengue
virusinfection
PositiveforZikavirusANDnegativefor
denguevirus
Notyetperformed
Notyetperformed
PresumptiverecentZikavirusinfection
PositivefordenguevirusANDnegative
forZikavirus
Notyetperformed
Notyetperformed
Presumptiverecentdenguevirus
infection
PositiveforZikavirusANDpositivefor
denguevirus
Notyetperformed
Notyetperformed
Presumptiverecentflavivirusvirus
infection
Equivocal(eitherorbothassays)
Notyetperformed
Notyetperformed
Equivocalresults
Notyetperformed
Notyetperformed
Inconclusiveresults
NegativeforZikavirusANDnegative
fordenguevirus
Notindicated
Notindicated
NoevidenceofrecentZikavirusor
denguevirusinfection
ELISA:enzymelinkedimmunosorbentassayIgM:immunoglobulinMantibodiesPRNT:plaquereductionneutralizationtest.
*ForpersonswithsuspectedZikavirusdisease,Zikavirusrealtimereversetranscriptionpolymerasechainreaction(rRTPCR)shouldbeperformedonserum
specimenscollected<7daysafteronsetofsymptomsandonurinespecimenscollected<14daysafteronsetofsymptoms.
IntheabsenceofrRTPCRtesting,negativeIgMorneutralizingantibodytestinginspecimenscollected<7daysafterillnessonsetmightreflectcollectionbefore
developmentofdetectableantibodiesanddoesnotruleoutinfectionwiththevirusforwhichtestingwasconducted.
ZikaIgMpositiveresultisreportedas"presumptivepositive"todenotetheneedtoperformconfirmatoryPRNT.
ReportanypositiveorequivocalIgMZikaordengueresultstostateorlocalhealthdepartment.
Toresolvefalsepositiveresultsthatmightbecausedbycrossreactivityornonspecificreactivity,presumptivepositiveZikaIgMresultsshouldbeconfirmedwith
PRNTtitersagainstZika,dengue,andotherflavivirusestowhichthepersonmighthavebeenexposed.Inaddition,equivocalandinconclusiveresultsthatarenot
resolvedbyretestingalsoshouldhavePRNTtitersperformedtoruleoutafalsepositiveresult.
26/28
29/9/2016
Reproducedfrom:RabeIB,StaplesJE,VillanuevaJ,etal.InterimGuidanceforInterpretationofZikaVirusAntibodyTestResults.MMWRMorbidMortalWklyRep2016.
27/28
29/9/2016
ContributorDisclosures
A.DesireeLaBeaud,MD,MS Nothingtodisclose MartinSHirsch,MD Nothingtodisclose ElinorLBaron,MD,DTMH Nothingtodisclose
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthroughamultilevel
reviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofall
authorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy
Close
TheuseofUpToDateissubjecttotheSuscripcinyAcuerdodelicencia.
28/28

Zika Virus Infection - An Overview - UpToDate

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Zika Virus Infection - An Overview - UpToDate

Uploaded by

Copyright:

Available Formats

29/9/2016

You might also like