EMERGING INFECTIONS:

ZIKA & JAPANESE ENCEPHALITIS

N I C O L E S . P E R R E R A S , M D, D P P S , D P I D S P
P E D I AT R I C I N F E C T I O U S D I S E A S E

1
 OBJECTIVES
• To discuss the re-emergence of JE and Zika in the Philippines
• To discuss each disease entity
– signs and symptoms
– diagnostics
– treatment and prevention

2
DISCLAIMER
• Nothing to declare
• No conflict of interest
JAPANESE
ENCEPHALITIS
 •\
JEFellow
ASPediatrician:
A PEDIATRICIAN
Kelangan ba tlga ng Jap
enceph vaccine?

Mommy 1: Doc, I’m going to Japan. I read in some

(mommy blog/mommy viber
group/Google/magazine) that I need this vaccine
to. prevent my kid from getting brain disease…Can
we see you now?

Mommy #2: Doc, I forgot to ask. My son’s next vaccine is JE.

Never heard of this…

Doc, may referral po kayo… 5 year old male na may dec

sensorium, seizure and fever…for opinion and co-
management po.Ty [NOD St. 6]
7
 ENZOOTIC CYCLE

• transmitted naturally between wild and domestic birds and pigs by

Culex mosquitoes
• C.tritaeniorrhynchus
• breeds in pools of stagnant water

Solomon et al, 2000

8
`

Lopez et al.2014
9
10
mosquito bite -> WBCs -> CNS -> virus binds to
endothelial surfaces of the CNS spreading the virus
from the peripheral areas to the CNS
JEV may also reside in astrocytes, which are part
of the body’s BBB
Incubation period: virus resides in WBCs

Solomon, 2004 NEJM

11
 1958 - 1993
Serologic surveys in the Phils.

1977 1982
1943 C.tritaeniorhynchus and JE Outbreak
1958 in Nueva
JEV Abs Cases reported C.vishnui mosquitoes -
discovered in Ilocos Sur Ecija
in Pampanga
horses

Lopez et al.2014 12
 Summary:
Age group: youngest 6 months
- majority were less
than 15 years of age
Among those tested for JE, 3-92%
tested positive

Lopez et al.2014
13
 Summary:
N = 257 laboratory-confirmed JE
cases
Among meningitis and encephalitis
cases, 7-18% were JE-+
Majority <15 years

14
 2009
WHO -> Western Pacific 2012-2013
laboratory network for JE Northern Mindanao
2008 Surveillance Medical Center
Philippine Integrated Philippine Children’s
Disease Surveillance 2011 Medical Center
and Response, San Lazaro Hospital
surveillance for acute RITM Western Visayas
encephalitis Medical Center
syndrome (AES), as a Bicol Medical Center JEVaccine
proxy for JE

Lopez et al.2014 15
WORLDWIDE INCIDENCE
• 3 billion at
risk
• 50,000 -
68,000 cases
annually
• 40,000
annually in Solomon et al, 2000
the Western Lopez et al.2014
Pacific region
16
 Yearly distribution of suspected and confirmed JE cases from
surveillance and clinician referral testing, January 2011 to December
2017
No. of No. tested No. of
suspected for JE laboratory
JE cases* confirmed
JE
2011** 199 64 16
2012** 352 129 24
2013** 392 237 25
2014** 226 67 8
2015*** 943 817 123
2016† 2,002 1,672 315
2017† 3,946 2,238 340

*Includes surveillance cases with and without specimens, and clinical referral cases
**Lopez AL, Aldaba JG, Roque VG Jr, Tandoc AO III, Sy AK, et al. (2015) Epidemiology of Japanese Encephalitis in the Philippines: A Systematic
Review. PLOS Neglected Tropical Diseases 9(3): e0003630. https://doi.org/10.1371/journal.pntd.0003630
http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003630
***AMES database only
†Consolidated data from AES, AMES and Bacterial Meningitis database
JEV IN THE PHILIPPINES

• Jan – April 2018

• N =1,274 meningoencephalitis cases
• 762, 60% male
• <1 month – 85 years (median: 3 years)
• 698, 55% <5 years old

18
JEV SURVEILLANCE
JUNE TO JULY 2018
21
22
CONFIRMED JE DEATHS

• Case 1: 4/M, Cagayan Valley Medical Center, Region II

• Case 2: 12/M, Mother Teresa of Calcutta Medical Center Pampanga, Region III
Each region had at least 1
suspected JE case.

81 provinces
- 68 reported suspected JE
cases
- 20 reported confirmed JE
cases

Lopez et al.2014
24
WHO ARE AFFECTED?

JE is suspected in all age

groups
- 68% <15 years
- 78% <19 years

Among confirmed JE cases

- 75% - <15 years
- 85% - <19 years

Lopez et al.2014
25
 Subject No. Year Age Type Citizenship Outcome Lab-confirmed JE vaccine

1 2005 65 Tourist-VFR US Survived Yes No

2 1998 57 Tourist Norway Died Yes Unknown

3 1998 65 Expatriate Norway Died Yes Unknown

4 1986 55 Soldier US Survived Unknown Unknown

5 1986 Unknown Soldier US Survived Unknown Unknown

26
WHEN ARE WE AT RISK FOR JE?

Peak: June and July

Confirmed JE cases
occurred in all months of
the year except November

Lopez et al.2014
27
WHICH PATIENTS BECOME SYMPTOMATIC?

• Endemic areas - most residents are infected by 15 years of age and

are immune
• ~10% of population are infected each year
• 1 in 25 to 1 in 1000 humans infected with Japanese encephalitis
virus develop clinical features of infection
• 1 in 250-1000 children are symptomatic versus 1 in 25 non-
immune adults (Solomon, 2004 NEHM)

Solomon et al 2000
28
 CASE DEFINITION
Acute Encephalitis Syndrome (AES)
Person of any age, at any time of the
year with the acute onset of fever and
at least one of:
Change in mental status - confusion,
disorientation, coma, inability
to talk
New onset of seizures - excluding
BFC
Other early clinical findings may include an
increase in irritability, somnolence or
abnormal behavior greater than that seen
with usual febrile illness
Suspected JE Case - Meets clinical case definition
for AES
Laboratory-confirmed JE: An AES case with JEV-specific
IgM Ab in CSF or serum detected by IgM-capture ELISA
Probable JE: An AES case that occurs in close geographical
and temporal relationship to a laboratory-confirmed case of
JE, in the context of an outbreak.
AES - other agent: An AES case in which diagnostic testing
is performed and an etiologic agent other than JE virus is
identified.
AES - unknown: An AES case in which no diagnostic testing
is performed or in which testing was performed but no
etiologic agent was identified or in which the test results
were indeterminate. Lopez et al.2014 29
 ACUTE ENCEPHALITIS SYNDROME IS A NOTIFIABLE DISEASE

• Research Institute for Tropical Medicine is the national JE

reference laboratory
• CSF and serum samples are coordinated with the Provincial
Epidemiology and Surveillance Unit (PESU) Regional
Epidemiology and Surveillance Unit (RESU)
• Results are released within 5-14 days depending on the
sample load

30
SIGNS AND SYMPTOMS
• 5-15 days incubation period
• non-specific febrile illness: coryza, diarrhea, rigors
• Mental status abnormalities
• abulia, masked facies, blank affect
• neurologic s/sxs -> headache, altered mental status, seizures
• hemiparesis, hemiplegia, cranial nerve palsies, movement disorders

Solomon et al 2000

31
SEIZURES
• occur in 85%
• predictor of poor outcome
• no particular seizure type: may be generalized tonic-clonic or subtle
motor types (twitching of a digit, eye, mouth, eye deviation, irregular
respiration)

Solomon et al 2000

32
PARKINSONIAN MOVEMENT DISORDERS
• acute stages and as part of sequelae
• mask-like facies, tremors, cogwheel rigidity
• generalized rigidity, opisthotonos, choreoathetosis, myoclonic jerks

Solomon et al 2000

33
34
POLIOMYELITIS-LIKE PARALYSIS
• short febrile illness -> rapid onset of flaccid paralysis in one or more
limbs
• normal level of consciousness
• weakness or flaccidity of limbs (legs>>arms) -> mostly the only feature
• reduced or absent reflexes
• 30% -> encephalitis
• acute flaccid paralysis similar to poliomyelitis
• can also occur in “classic” JE cases that follow the usual course

Solomon et al 2000
35
36
Symptoms No. of Cases (%) Symptoms No. of Cases (%)
N = 52 N = 52

Fever 52 (100)
Altered sensorium 45 (87)
Headache 35 (67)
Seizures 35 (67)
Vomiting 30 (58)
Dysphasia 35 (67)
Chills 23 (44) Paralysis 13 (25)
Nausea 11 (21) Behavioral changes 12 (23) San Luis, 1990
Dizziness 5 (10) 37
• abulia with masked facies
• variable changes in mentation
• relative absence of cranial nerve involvement
• lack of gross sensory deficit
• asymmetric and irregular motor and tone abnormality

38
RITM SENTINEL SURVEILLANCE FOR ETIOLOGIC
DIAGNOSIS OF
MENINGITIS/ENCEPHALITIS/MENINGOENCEPHALITIS IN
THE PHILIPPINES
ESPINO, 2014 (UNPUBLISHED)

• N = 251
• 2mos - 18 years old
• WHO case definition of CNS infection
• Analytic tests:
• CSF: latex agglutination for antibodies to bacterial pathogens
(Bactigen), JEV/DENV IgM-capture ELISA and real time PCR
• Serum: JEV/DENV IgM ELISA

39
PREDICTORS OF OUTCOME
• exposure to previous flavivirus infection protective due to cross-
reacting antibodies (Solomon, 2004 NEJM)
• serial infection with different dengue serotypes may be associated
with more severe disease -> antibody enhancement of infection

45
OUTCOMES

• Case fatality rates - 30 - 50%

• long-term neuropsychological sequelae in 30–50% of its survivors
(Children>adults)
• 30% have frank motor deficits
• 20% have severe cognitive impairment

Ooi et al. 2008

Lopez et al.2014
Solomon et al, 2000 46
• increased CSF opening pressure -> predictor of poor outcome
• CSF pleocytosis of 10-100 cells/mm3
– predominant lymphocytes
– mildly increased protein (50-200 mg%)
– normal CSF:serum glucose ratio

47
 Occurrence of cross-
reaction with dengue virus
Ag
Year No. of JE
and DNV (+)
Samples

2002 4
• January 2002-October 2005
• San Lazaro Hospital, St. Luke’s Medical Center 2003 5

QC, DOH 2004 8

• N = 614 patients with s/sxs of meningitis and/or
2005 0
encephalitis
• 11.7% JE TOTAL 17 (24%)

48
 SUSPECTED VERSUS CONFIRMED CASES OF JE
JANUARY 2011 - MARCH 2014

Year # of Suspected JE No. of Cases Tested No (%) Confirmed JE

Cases for JE
2011 199 64 16 (25%)

2012 352 129 24 (19%)

2013 392 237 25 (11%)

2014 89 67 8 (12%)
(Jan-Mar)

2011-2014 1032 497 73 (15%)

49
SERUM AND CSF IGM

50
A serum sample should be obtained at admission. Because it may not yet be
positive in a JE-infected person, a second serum sample should be collected at
discharge or on the 10th day of illness onset (usually around 7 days after admission)
or at the time of death and tested for presence of JE virus specific IgM.

CSF is the preferred sample for diagnosis of JE.

51
 Severe sequelae
Outcome grade No (%) patients

Death 10 (8) Severe cognitive impairment with spastic quadriparesis

Severe sequelae 33 (28) Severe cognitive impairment with no gross motor

impairment
Mutism with quadriparxsis
Moderate sequelae 28 (24)
Mutism
Mild sequelae 3 (3) Mutism and hemiplegia

Full recovery 44 (37) Mentally normal but bed-bound because of quadriparesis

Isolated swallowing difficulty requiring NGT feeding 52
 TREATMENT

• No specific antiviral treatment for JE

• Symptomatic treatments
– Fever should be treated using antipyretics based on paracetamol
– Seizures control with diazepam, clonazepam or phenytoin
– Intracranial hypertension control by hyperventilation and mannitol
– Parenteral nutrition, fluid and electrolytic balance, and judicious use of antibiotics
are required.
– Airway protection to prevent aspiration pneumonia in case of reduced gag reflex
– Careful nursing care and physiotherapy to reduce the risk of bedsores,
malnutrition and contractures.

Diagana (2007).
53
PREVENTION

• Vaccination is the single, most important control measure

Lopez et al.2014
54
ZIK A VIRUS
 THE ZIKA
VIRUS

enveloped virus
Stable up to 40°C
Kostyuchenko, VA et al. (2016). Structure of the thermally stable Zika virus. Nature, advance
online publication. doi: 10.1038/nature17994
 THE ZIKA VIRUS

RNA virus
Flavivirus genus,
Flaviviridae family

Closely related DENV

2 strains (early African and

contemporary Asian lineages) with only
1 serotype

Dowd et al., 2016, Cell Reports 16, 1485–1491. http://dx.doi.org/10.1016/j.celrep.2016.07.049

 ZIKA TIMELINE
2013-2014
Outbreaks in 4 Nov 11, 2015
groups of Pacific Brazil: national Feb 2016
islands: possible health emergency WHO declares
association bet -> WHO asks recent association
Oct 30, 2015
Zika and countries to of Zika with
Brazil: increase in
neurologic report increases clusters of
microcephaly cases
complications and in microcephaly microcephaly
among newborns ->
congenital and other CNS constitute a
reports in neighboring
malformations malformations Public Health
countries
Emergency of Intl
Concern
• In regions with NO active Zika virus transmission
– Men and women returning from areas where transmission of Zika virus is known to occur should
adopt safer sex practices or consider abstinence for at least 6 months upon return to prevent Zika
virus infection through sexual transmission.
– Couples or women planning a pregnancy, who are returning from areas where transmission of Zika
virus is known to occur, are advised to wait at least 6 months before trying to conceive to ensure
c

that possible Zika virus infection has cleared.

– Sexual partners of pregnant women, returning from areas where transmission of Zika virus is known
to occur, should be advised to practice safer sex or abstain from sexual activity for at least the
a

whole duration of the pregnancy.

ZIKA TIMELINE

Oct 1, 2016
Thailand notifies
WHO of 2 babies
born with
microcephaly
(first cases in
SEA)
 Mosquito bite

Viral replication occurs in local

dendritic cells with subsequent spread
to lymph nodes

Virus may be detectable in blood as

early as Day 1 of symptoms, peak
viremia at 3-5 days, may persist up to 11
days

Other body fluids

Protective immunity
Edward, B. Hayes. (2009). Zika Virus Outside Africa. Emerging Infectious Disease journal,
15(9), 1347. doi: 10.3201/eid1509.090442
 ZIKA VIRUS DISEASE
Incubation Period: 3-14 days
For symptomatic persons with symptoms >2 weeks
after travel, transmission might be not travel associated.

Duration of symptoms: 2-7 days

(if symptomatic)

1. Elisabeth, R. Krow-Lucal, Brad, J. Biggerstaff, & Staples, J. Erin. (2017). Estimated Incubation Period for
Zika Virus Disease. Emerging Infectious Disease journal, 23(5), 841. doi: 10.3201/eid2305.161715
2. Duffy, M.R., Chen, T.H., Hancock, W.T., Powers, A.M., Kool, J.L., et al. Zika virus outbreak on Yap
Island, Federated States of Micronesia. N Engl J Med. 2009; 360: 2536–2543
3. US CDC . Zika Virus: For Health Care Providers: Clinical Evaluation & Disease.
 GOOD NEWS
Zika is a mild disease.

80%
of infected patients will be asymptomatic
1. Duffy, M.R., Chen, T.H., Hancock,W.T., Powers, A.M., Kool, J.L., Lanciotti, R.S. et al. Zika virus outbreak on Yap Island,
Federated States of Micronesia. N Engl J Med. 2009; 360: 2536–2543
2. Interim Guidelines for Pregnant Women During a Zika Virus Outbreak — United States, 2016
Weekly / January 22, 2016 / 65(2);30–33
GOOD NEWS
Zika is a mild disease.
CLINICAL MANIFESTATIONS OF
ZVD

Mo, Yin, Brenda Mae Alferez Salada, and Paul Anantharajah Tambyah. "Zika Virus—a Review for
Clinicians." British Medical Bulletin 119, no. 1 (September 1, 2016 2016): 25-36.
CLINICAL MANIFESTATIONS OF
Symptom ZVD
Rio de Janeiro, 2015, n=57

Exanthema 56 (98)
Fever 38 (67)
Arthralgia 33 (58)
Headache 38 (67)
Myalgia 28 (49)
Retro-orbital pain 23 (40)
Conjunctivitis 22 (39)
Joint swelling 13 (23)

Cerbino-Neto J, Mesquita EC, Souza TML, Parreira V, Wittlin BB, Durovni B, et al. Clinical
manifestations of Zika virus infection, Rio de Janeiro, Brazil, 2015 [letter]. Emerg Infect Dis. 2016 Jul
[28 October 2016].
CLINICAL MANIFESTATIONS OF
Symptom
Macular or papular rash
ZVD
Rio de Janeiro, 2015, n=119
115 (97)
Severe weakness 94 (79)
Headache 78 (66)
Arthralgia 75 (63)
Myalgia 73 (61)
Non-purulent conjunctivitis 66 (56)
Retro-orbital pain 53 (45)
Lymph node enlargement 49 (41)
Fever 43 (36)
Anorexia 42 (35)
Photophobia 41 (35)

Brasil P, et al. Zika Virus Outbreak in Rio de Janeiro, Brazil: Clinical Characterization,
Epidemiological and Virological Aspects. PLoS Negl Trop Dis. 2016 Apr 12;10(4):e0004636. doi:
10.1371/journal.pntd.0004636. eCollection 2016.
 W.E.Villamil-Gómez, et al.
Dengue, Chikungunya and
Zika co-infection in a patient
from Colombia. J Infect
Public Health (2015)

Aletti M, et al. [Zika virus maculopapular

exanthema in traveller returning from
Martinique to Mainland France] [Article in
French]. Presse Med. 2016 Oct;45(10):939-940.
doi: 10.1016/j.lpm.2016.06.003. Epub 2016 Jul
27.
Mayo Clinic Proceedings 2016 91, 514-521DOI: (10.1016/j.mayocp.2016.02.017)
 FEVER IN ZIKA
Low grade (37.8 C – 38.5 C)
Short-lived

US CDC. Clinical Guidance for Healthcare Providers for Prevention of Sexual

Transmission of Zika Virus. https://www.cdc.gov/zika/hc-providers/clinical-guidance/
sexualtransmission.html
W.E. Villamil-Gómez, et al. Dengue, Chikungunya and
Zika co-infection in a patient from Colombia. J Infect
Public Health (2015)
 Profile of Locally Confirmed Zika Cases by PCR,
February 18, 2016 – August 7, 2018 (n=68)

• Age range: 4 – 59 years old (median=32 years)

• Female = 48; Male=20
• Nine (13%) were pregnant
• Three pregnant cases were from NCR and CALABARZON, two from Central Visayas and
one from Region I
• All of the pregnant cases delivered full term except for one who had a spontaneous abortion
at 9 weeks AOG**

**AOG or age of gestation

DI S TR I BU TI O N O F Z I K A CO NF I RM E D CA S E S TE S TE D I N RI TM BY
AGE AND S E X , FE BRU ARY 18, 20 16 – A U GU S T 7, 20 18 (N=68)

Age Range

Number of Cases
 Signs and Symptoms of Confirmed Zika Cases Tested in
RITM, February 18, 2016 – January 17, 2018 (n=68)*

Signs and symptoms

Number of cases
*Multiple Responses
 Map of Locally Confirmed Zika Cases,
February 18, 2016 – January 17, 2018 (n=68)

Region I = 3

Region III = 2
NCR = 24

CALABARZON = 20

Region V = 1

Region VI = 16

Region VII = 2
 GOOD NEWS
Once a person has been infected, he or she
is likely to be protected from future
infections.

https://www.cdc.gov/zika/about/questions.html
Pardi, Norbert, Hogan, et al. (2017). Zika virus protection by a single low-dose nucleoside-modified
mRNA vaccination. Nature, 543(7644), 248-251. doi: 10.1038/nature21428
http://www.nature.com/nature/journal/v543/n7644/abs/nature21428.html#supplementary-information
BAD NEWS
ZIKV has been demonstrated to
exhibit neurotropism.
Guillain
MicrocephalyBarre Syndrome
 ZIKA IN PREGNANT MOTHERS
• No clinical differences have been described between
pregnant and non-pregnant women
• Pregnant women who have a ZIKV infection experience
symptoms concordant with the rate observed in the
general population.

WHO/PAHO. Provisional remarks on Zika virus infection in pregnant women:

Document for health care professionals (January 25, 2016).
CONGENITAL ZIKA VIRUS SYNDROME
• Craniofacial disproportion, spasticity, seizures, irritability, brainstem dysfunction
• Limb contractures
• Hearing and ocular abnormalities
• Neuroimaging: cortical/subcortical calcifications, cortical malformations, simplified gyral
pattern/migrational abnormalities, brainstem/cerebellar hypoplasia, and ventriculomegaly.
• 1 in 5 normal head circumference
• Measurement of HC in the first 24 hours of life and assessment for craniofacial disproportion
• All mothers asked about clinical s/sx of Zika infection and/or lab confirmation of Zika during
pregnancy
• Microcephaly -> assess hearing and vision
• Neuroimaging
– Zika is suspected in mother during pregnancy
– Neurological s/sxs in the newborn
– CT scan or MRI; cranial ultrasound is less useful
• Rule out TORCH
• Ophthalmologic assessment
NEUROIMAGING
• Subcortical cerebral calcification
• brain atrophy and ventriculomegaly, cerebellar and brainstem anomalies, cortical gyral
abnormalities and callosal abnormalities.
• Gyral abnormalities especially frontal polymirogyria
• These may also be found in congenital CMV
• CT Scan: imaging of choice

Petersen et al.NEJM (2016).

Profile of Pregnant Confirmed Zika Cases by
PCR, February 18, 2016 to June 21, 2017 (n=7)
Municipality/City No. of Cases Current Status of Pregnancy
16 years old, delivered a full term, male
Las Piñas City neonate, non-microcephalic via normal
1 spontaneous vaginal delivery
27 years old; delivered a full term, male
Biñan, Laguna
1 neonate, non-microcephalic
22 years old, delivered a full term, male
Brgy. Luz, Cebu City neonate, non-microcephalic via caesarian
1 section
32 years old; No fetal heartbeat upon
Brgy. Lahug, Cebu City ultrasound; non-microcephalic, spontaneous
1 abortion at 9 weeks AOG*
32 years old, 39 weeks AOG; delivered a full
Pasay City term, non-microcephalic, male neonate via low
1 transverse Caesarian Section
33 years old; delivered a full term, non-
Quezon City microcephalic, male neonate via low transverse
1 Caesarian Section
24 years old; delivered a full-term, male
Ternate, Cavite
1 neonate, non-microcephalic
Total 7 Ongoing Monitoring
CASE FATALITY
RATE OF ZIKA IS
VERY LOW.
 DEATHS FROM ZIKA

• Associated with other diseases such as pneumonia

• Several cases associated with Guillain-Barre
Syndrome
• 1 died from severe thrombocytopenia (Colombia)
• Zika as direct cause of death remains to be studied.
 CAN ZIKA BE
TRANSMITTED BY:
Yes No Possible
 Pregnant mother to her fetus
 Previously infected women who became pregnant
to her fetus

Recommendation
For confirmed cases, ensure the she is not
shedding virus anymore before pregnancy.
 CAN ZIKA BE TRANSMITTED
BY:
Yes No Possible

 Breastfeeding
• The virus has been detected in breast milk.
• BUT, breastfeeding-associated transmission has not
been reported so far

The benefits of breastfeeding for the infant and

mother outweigh any potential risk of Zika virus
transmission through breastmilk.

WHO. June 2016. Infant feeding in areas of Zika virus transmission.

http://apps.who.int/iris/bitstream/10665/204473/1/WHO_ZIKV_MOC_16.5_eng.pdf?ua=1
Besnard M, et al. Evidence of perinatal transmission of Zika virus, French Polynesia, December 2013 and February 2014. Euro surveill.
2014;19(13):
WHO. Zika virus and complications: Questions and answers Online Q&A. Updated 10 March 2017
 CAN ZIKA BE
TRANSMITTED BY:
Yes No Possible
 Blood transfusion
• The potential for transfusion-transmitted Zika virus was shown in
French Polynesia where 2·8% of asymptomatic blood donors tested
were positive for ZIKV
• Two possible cases of transfusion-transmitted Zika virus infections
Temporary deferral of blood donors from epidemic
locations, donor self-reporting of Zika virus symptoms,
and focus on at-risk recipients

Musso, Didier, Susan L. Stramer, and Michael P. Busch. "Zika Virus: A New Challenge for Blood
Transfusion." The Lancet 387, no. 10032 (1993-94.
 CAN ZIKA BE
TRANSMITTED BY:
Yes No Possible
 Sexual transmission
• Zika has been found in genital fluids, including semen and vaginal
fluids.
• Studies are underway to find out how long (69-188 days)
• This includes vaginal, anal, and oral sex and the sharing of sex toys.

Abstinence. Barrier protection for pregnant women.

http://www.cdc.gov/zika/pdfs/zika-key-messages.pdf
 HOW DO WE
DIAGNOSE
SYMPTOMATIC ZIKA
LOCALLY?
Detection of ZIKV RNA via PCR
in urine and blood specimens
National Reference Laboratory for Dengue and other
Arboviruses
at the Research Institute for Tropical Medicine
 DOH CASE DEFINITIONS
SUSPECTED CASE OF ZIKA VIRUS INFECTION
A patient with skin rash and one of the following:
– Fever (<38.5ºC) or reported history of fever within the past five (5) days prior to
consultation
– Arthralgia
– Arthritis
– Conjunctivitis
B. A mother whose fetus, newborn or infant has any neurological condition listed
below that cannot be explained by other etiologies:
– Head circumference less than the -3 Standard Deviation (<-3SD) or occipito-frontal
circumference less than the 3rd percentile on standard growth charts, OR
– Disproportionately small head as compared to infant’s length, OR
– Intra-cranial calcifications
C. A fetus, newborn or infant whose mother had confirmed or presumed infection
with Zika virus during pregnancy.
D. All newly diagnosed Guillain-Barre Syndrome (GBS)
94
DOH DM 2016-0116A Interim Guidelines on the Zika Virus Disease Surveillance
 SUMMARY OF SPECIMEN COLLECTION, STORAGE, AND
TRANSPORT FOR ZIKA TESTING

Sample Timing of Condition Quanti Storage Transport

Type Collection s ty
*Blood- Within 5 For general 5 ml Refrigerator, Transport
Acute days after population 2 to 8°C within 48
Phase onset of hours/ 2
symptoms days after
collection
*Urine 5 to 14 days For general 10 ml Refrigerator, Transport
after onset population 2 to 8°C within 48
of symptoms hours/ 2
days after
collection
DOH Department Memo No. 2016-0116-A 95
 SUMMARY OF SPECIMEN COLLECTION, STORAGE, AND
TRANSPORT FOR ZIKA TESTING
Sample Type Timing of Conditions Quantity Storage Transport
Collection
Amniotic ≥ 15 gestational weeks For pregnant 1 ml Refrigerator, 2 to Transport within 48
Fluid suspected case 8°C hours/ 2 days after
collection
Placenta Immediately after birth For new born infant 2 Fresh Frozen Room Transport within 3
(To include of suspected Paraffin Embedded temperature days after collection
umbilical mother cassette blocks
cord, AND
placenta, and 2 Formalin-fixed
placental Paraffin Embedded
membrane) cassette blocks

Cord Blood Immediately after birth For new born infant 5 ml Refrigerator, 2 to Transport within 48
of suspected 8°C hours/ 2 days after
mother collection
CSF Upon first contact or If with CNS 1 ml Refrigerator, 2 to Transport within 48
when possible manifestations 8°C hours/ 2 days after
collection
NPS/OPS Collect within 5 days If suspected for 1 VTM or UTM Refrigerator, 2 to Transport within 3
after onset when Measles or Rubella 8°C days after collection
suspecting for Measles
or Rubella 96
TRANSPORT TO RITM
6-8 frozen icepacks

Transported within 48
hours
Intact Correct Package and preserve
container temperature specimens
Arrange shipment
(Courier)
International Air Transport Association
Within time Properly (IATA) Regulations Compliant
limits labeled
 TURN-AROUNT TIME (TAT)
5 working days from the time of receipt of
specimen at RITM.
 GENERAL FLOW- CURRENT
Case
detection DOH Disease Prevention and Epidemiology
Control Program (DPCB) Bureau

Sample Storage in
Collection the hospital
Shipment to Lab Testing
from laboratory
RITM at RITM
suspected prior to
cases shipment

SENTINEL SITE TESTING SITE

HOSPITAL
 SEROLOGIC TESTING FOR ZIKA
• ZikV IgM and IgG antibody testing available for research purposes for now
– Cross – reactivity with dengue
• Requires confirmation with PRNT (plaque reduction neutralization test)  not yet available locally

Eppes. Testing for Zika virus infection in pregnancy. Am J Obstet

Gynecol 2017 100
THANK YOU