Annals of Internal Medicine

IDEAS AND OPINIONS

Personal Actions to Minimize Mosquito-Borne Illnesses, Including

Zika Virus
Regina L. LaRocque, MD, MPH, and Edward T. Ryan, MD

any viral and parasitic diseases are transmitted

by mosquitoes. Different species of mosquitoes
spread different illnesses and bite at different times of
the day. Anopheline mosquitoes usually bite from dusk
until dawn and can transmit malaria. Culex mosquitoes
often bite from evening until morning and can transmit
West Nile virus. Aedes mosquitoes primarily bite during the day, although they can also bite at night; these
are the mosquitoes that can transmit Zika, dengue, and
chikungunya viruses (1 4).
Diseases spread by aedes mosquitoes have raised
increasing concern in the Caribbean Basin and areas of
Latin America in recent years. Dengue virus has long
been endemic in the region and can manifest as a nonspecic febrile or hemorrhagic illness. Chikungunya virus was rst recognized in the Americas in late 2013
and can manifest as a nonspecic febrile illness with
arthritis that may be prolonged. Most recently, in 2015,
the Pan American Health Organization issued an alert
after the rst conrmed cases of Zika virus infection in
the Americas were reported in Brazil. Since that time,
the epidemic has grown. Although most patients who
acquire Zika virus remain asymptomatic, approximately
1 in 5 develops a nonspecic febrile illness that may
include conjunctivitis. Of greatest concern, Zika virus
can cause fetal microcephaly in women who acquire it
while pregnant.
Since the recent introduction of chikungunya and
Zika viruses into the Western hemisphere, both have
spread rapidly, reecting the widespread distribution
of 2 aedes mosquito vectors that are capable of transmitting these pathogens: Aedes aegypti and A albopictus. Of note, both are distributed across substantial regions of the United States, raising concern for the
possibility of local transmission (www.cdc.gov/zika
/vector/index.html). Many steps fortunately can be
taken to limit mosquito-borne illnesses, including trip
planning; personal protective measures; household
treatment; and, in the case of malaria, chemoprophylaxis (www.cdc.gov/zika/prevention/index.html and
www.cdc.gov/malaria/travelers/index.html).
First, persons can restrict travel to areas with active
transmission of such mosquito-borne illnesses as Zika,
chikungunya, or dengue viruses. Up-to-date surveillance data and travel recommendations are available
through the Centers for Disease Control and Prevention (CDC) (www.cdc.gov). Pregnant women should not
travel to areas with Zika virus transmission (wwwnc.cdc
.gov/travel/page/zika-information).
Second, exposure to mosquitoes should be limited, especially during peak biting times. Persons
should wear long-sleeved shirts and long pants and

cover their feet when outside. The use of window

screens and air conditioning can minimize mosquito
exposure while indoors. Bed nets should be used at
night, particularly in areas where malaria is present.
The correct and consistent use of insect repellents
is essential for preventing mosquito and tick bites. Although many products that purport to have repellent
activity are available (5), the CDC recommends use of
only Environmental Protection Agencyregistered repellents with one of the following active ingredients:
DEET (N,N-diethyl-meta-toluamide), picaridin, IR3535,
oil of lemon eucalyptus, or para-menthane-3,8-diol
(www.cdc.gov/zika/prevention/index.html). The Environmental Protection Agency maintains a Web site that
allows direct comparison of various products containing these active ingredients, including whether they
protect against mosquitoes, ticks, or both; their active
ingredients; and their duration of protection (www.epa
.gov/insect-repellents/nd-insect-repellent-right-you).
Manufacturers' instructions should be followed carefully, specically applying and reapplying the repellent
as directed and not applying it under or directly to
clothes. If used, sunscreen should be applied before
insect repellent. Persons also may treat clothing and
other gear with permethrin, which often remains protective through multiple washings. Product directions
should be followed, and permethrin should not be
used directly on skin.
Mosquito avoidance measures in children and
pregnant women raise special concerns. The CDC recommends dressing children in clothing that covers
arms and legs; covering cribs, strollers, and baby carriages with mosquito netting; not applying insect repellent onto a child's hands, eyes, mouth, or open or irritated skin or at all on babies younger than 2 months;
and not using any product containing oil of lemon
eucalyptus or para-menthane-3,8-diol on children
younger than 3 years (www.cdc.gov/chikungunya/pdfs
/fs_mosquito_bite_prevention_travelers.pdf).
When
used as directed, Environmental Protection Agency
registered insect repellents are safe and effective, including in breastfeeding and pregnant women.
Third, measures should be taken to control
mosquitoes in and around the home (www.cdc.gov
/zika/prevention/controlling-mosquitoes-at-home.html).
Aedes mosquitoes often lay eggs in small containers
that hold standing water in houses; covering or discarding such items and emptying, draining, and scrubbing water-holding items, such as vases and ower pot
saucers, should be done at least weekly. Persons can
also kill mosquitoes in their homes by using indoor ying insect fogger or indoor insect spray. These prod-

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Annals of Internal Medicine

IDEAS AND OPINIONS

ucts work immediately but need to be reapplied. Label
instructions should be carefully followed. Mosquitoes
often rest in dark, humid places, such as in laundry
rooms, under furniture, in closets, or under sinks.
Any items around the home that can catch or collect water, such as trash or leaves, should be picked up
and discarded. Once a week, persons should empty
and scrub, turn over, cover, or throw away such items,
as well as buckets, tires, planters, toys, pools, birdbaths,
ower pots and their saucers, or trash containers. Any
outdoor item that could collect water and thus permit
mosquitoes to lay eggs should be tightly covered or
drained, including buckets, cisterns, and rain barrels.
To prevent malaria, additional precautions include
the use of destination-appropriate chemoprophylaxis.
Further resources for minimizing illness during travel
are available at www.HeadingHomeHealthy.org.
Integrated vector-control programs that include
surveillance activities, elimination and removal of habitats that produce mosquitoes (source reduction), larvicidal application, neighborhood and environmental insecticide spraying to target adult mosquitoes, as well as
other interventions are usually directed by public
health authorities and tailored to the particular vector
or vectors being targeted (www.cdc.gov/zika/vector
/vector-control.html).
Of note, if persons believe that they have acquired
a mosquito-borne illness, they should continue to minimize the likelihood of being bitten by mosquitoes to
reduce possible transmission to household members
or within the community. Because many persons with
Zika virus are asymptomatic, the CDC also recommends that even travelers returning to the mainland
United States from an area with Zika virus who do not
feel sick should take steps to prevent mosquito bites
for 3 weeks after their return so that they do not spread
this virus to uninfected mosquitoes (wwwnc.cdc.gov
/travel/diseases/zika). In addition to limiting mosquito
exposure, persons who have been exposed to or become ill from Zika virus should follow the CDC's recom-

2 Annals of Internal Medicine

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Personal Actions to Minimize Mosquito-Borne Illnesses

mendations to limit the likelihood of sexual transmission of this virus, including through abstinence or the
consistent and correct use of condoms (www.cdc.gov
/zika/prevention/index.html#prevent).
From Massachusetts General Hospital, and Harvard University,
Boston, Massachusetts.
Grant Support: By U01CK000175 from the Centers for Dis-

ease Control and Prevention.

Disclosures: Disclosures can be viewed at www.acponline

.org/authors/icmje/ConictOfInterestForms.do?msNum=M16
-1397.
Requests for Single Reprints: Edward T. Ryan, MD, Division of

Infectious Diseases, Massachusetts General Hospital, Jackson

504, 55 Fruit Street, Boston, MA 02114; e-mail, etryan
@mgh.harvard.edu.
Current author addresses and author contributions are available at www.annals.org.
Ann Intern Med. doi:10.7326/M16-1397

References
1. Anderson KB, Thomas SJ, Endy TP. The emergence of Zika virus:
a narrative review. Ann Intern Med. 2016. [PMID: 27135717] doi:10
.7326/M16-0617
2. Chen LH, Hamer DH. Zika virus: rapid spread in the Western hemisphere. Ann Intern Med. 2016;164:613-5. [PMID: 26832396] doi:10
.7326/M16-0150
3. Petersen LR, Jamieson DJ, Powers AM, Honein MA. Zika virus.
N Engl J Med. 2016;374:1552-63. [PMID: 27028561] doi:10.1056
/NEJMra1602113
4. Weaver SC, Lecuit M. Chikungunya virus and the global spread of
a mosquito-borne disease. N Engl J Med. 2015;372:1231-9. [PMID:
25806915] doi:10.1056/NEJMra1406035
5. Lupi E, Hatz C, Schlagenhauf P. The efcacy of repellents against
Aedes, Anopheles, Culex and Ixodes spp.a literature review. Travel
Med Infect Dis. 2013;11:374-411. [PMID: 24201040] doi:10.1016/j
.tmaid.2013.10.005

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Current Author Addresses: Drs. LaRocque and Ryan: Division

of Infectious Diseases, Massachusetts General Hospital, Jackson 504, 55 Fruit Street, Boston, MA 02114.

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Author Contributions: Conception and design: R.L. LaRocque,

E.T. Ryan.
Drafting of the article: R.L. LaRocque, E.T. Ryan.
Critical revision of the article for important intellectual content: E.T. Ryan.
Final approval of the article: R.L. LaRocque, E.T. Ryan.
Obtaining of funding: R.L. LaRocque.

Annals of Internal Medicine