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All posts by Dr. Tahmoures Bahrami

Countries with Yellow Fever Virus Transmission – Date Of Last Outbreak

Africa Yr of last outbreak # of Cases
Angola 1988/2016 37 / 861
Benin 2004 31
Burkina Faso 2011 1024
Burundi 1995 260
Cameroon 11/12/13/14 29 & 31 &15& 3
Central African Republic 2011/2013 7 & 4
Chad 11/12/13/2016 122 /48 / 5 /?
Congo 2011/2012/2013 188 & 1 & 1
Cote d”Ivoire 11/12/13/14 10 & 4 & 6 & 21
Democratic Republic of Congo 11/12/13/14/2016 195 / 1/& 9 / 3 / 9
Equatorial Guinea 2008 10
Ethiopia 2013 223
Gabon 2006 57
Gambia 2012 1
Ghana 11/12/13/2016 30 & 3 & 7 & 4
Guinea 2010/2013/2014 2 & 2 & 2
Guinea Bissau 1999 4
Kenya 1995 11
Liberia 2012/2014 17 & 1
Mali 2010/2014 3 & 1
Mauritania 2003 10
Niger 2011 20
Nigeria 2011 387
Rwanda 0
Senegal 2011/2012/2013 7 & 1 & 2
Sierre Leone 2011/2012/2013 361 & 94 & 3
South Sudan 2011 128
Sudan 2012/2013 849/148
Togo 2012 12
Uganda 2011/2012/2016 66 & 32 & 7
 
South America Yr of last outbreak # of Cases
Argentina 2008 8
Bolivia 12/11/2013 2 & 3 & 1
Brazil 10/13/14/15/2016 2 /3/ 1/ 5/?
Colombia 2009/2013/2016 5 / 1 / ?
Ecuador 2012 1
French Guiana 0
Guyana 0
Panama 0
Paraguay 2008 28
Peru 11/12/13/14/15/16 13 /9/ 21/ 15 /17/ 14
Suriname 0
Trinidad & Tobago 0
Venezuela 2005 12
Other Countries (*Imported Cases)
Canada 2012/2014 3 & 5
China 2016 11
DR of C 2016 59
Georgia 2004 1
Haiti 2011 6
Kenya 2016 2
Namibia 2008 3
Spain 2009 1
 Source:
http://apps.who.int/immunization_monitoring/globalsummary/timeseries/tsincidenceyfever.html
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Yellow Fever Requirements in Brazil

“Temporary Requirement” by the Brazilian Ministry of Health (from the 1st half of July 2016) for travellers coming from or intended to arrive from the Democratic Republic of Congo and Angola. The measure is a
recommendation of the World Health Organization (WHO) Emergency Committee, because of urban yellow fever outbreaks ongoing in both countries since December last year [2015].

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traveling china vaccination

Traveling to China, What You Need to Know

According to the World Tourism Organization, tourism is increasing in China and the country is set to become the world’s largest tourist destination by the year 2020. The Chinese government is opening more attractions and regions in the country to foreign tourists. Even though tourism in the country is opening up it can still be challenge to travel in the country due to language barriers and travel restrictions. Today most travelers opt for guided tours.

What Vaccinations will I Need to Travel to China?

The Public Health Agency of Canada recommends travelers get vaccinated for the following diseases before traveling to China:

Hepatitis A – this disease is spread through contaminated food, water, or contact with an infected person. This vaccine is especially recommended if you plan to sample some of the many street food offerings during your travels.

Hepatitis B – is a serious liver disease that can be spread through the exchange of bodily fluids, sexual intercourse, and the use of an infected piercing tool or needle.

Rabies – Travelers to China should be vaccinated against rabies as the country has one of the highest numbers of reported cases of rabies in the world. Rabies is spread through the saliva of an infected animal.

Japanese Encephalitis – This disease is prevalent in most Asian countries. Vaccination is recommended for travelers who plan to spend time in the southern parts of China where irrigation is still done through flooding or travelers who plan to spend a lot of time outdoors.

Polio – China has not had a reported case of polio since 1994 but the country borders on Pakistan and Afghanistan where the polio virus is still epidemic.

Are there Other Infections I should Know About?

Travelers should be aware mosquitoes carrying the Malaria virus have been found in the Yunnan Province near the China and Myanmar border. The risk is low to most travelers.

Avian Influenza has been reported in humans since 2013 in China. Most cases of the avian influenza have occurred in the southern and eastern parts of China including Taiwan and Hong Kong. Two travelers from Canada were reported to have contracted the virus after a trip to China in 2015.

How Safe is China

Travel is relatively safe in China. The risk of violent crime is very low in China as is the chance of being robbed or raped. Travelers should be aware pick pocketing is very common in tourist destinations and at transit stations.

Train stations and subways have bag scanners and police at the gates to scan bags for sharp objects and check the content of water bottles. For the most part, officials are checking for domestic terrorism threats.

Domestic terrorism is a concern in the westernmost part of China in the Xinjiang Uyghur region where political and religious unrest has led to violence in recent years.

The biggest threat to travelers in China is the traffic. Cars have the right of way in China, exercise caution when crossing streets. Ask for a business card from your hotel in both Chinese and English to help you get back to the hotel if you become lost.

A travel specialist at Markham Travel Health can help answer all of your questions about your trip to China.

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yellow fever disease

The Problem of Yellow Fever Vaccine Supply and Demand in Angola and Beyond

Yellow fever, caused by yellow fever virus, is a mosquito-borne flavivirus disease; it is found in sub-Saharan Africa and tropical South America, where approximately 1 billion people in 46 countries are at risk for it. A live attenuated vaccine (strain 17D) was developed by Max Theiler and colleagues in the 1930s — work that earned Theiler a Nobel Prize. An excellent vaccine, it has been in use since 1937; more than 650 million doses have been distributed in the past 75 years, and 1 dose probably confers lifelong protective immunity. The disease, however, has not been conquered: there are still an estimated 180,000 cases and 78,000 resulting deaths every year.

In the past 6 months, we’ve seen a major resurgence of yellow fever disease that has proved difficult to control in multiple African countries. As a result, the World Health Organization (WHO) announced on May 19 that it had convened an emergency committee under the International Health Regulations to review the situation. That committee decided that the current epidemic is a “serious public health concern” but does not, unlike the current Zika virus epidemic, constitute a Public Health Emergency of International Concern.

How did this situation arise? In December 2015, a yellow fever outbreak was identified in Angola. That outbreak continues, despite distribution of nearly 12 million doses of vaccine in the country, and as of May 20, 2016, a total of 2420 suspected cases, including 298 deaths, had been reported. Alarmingly, the cases are not limited to Angola: the virus has spread, by way of infected travelers from Angola, to the Democratic Republic of Congo (DRC), Kenya, and China, further demonstrating the difficulty of controlling infectious diseases in this era of unprecedented mobility.

In addition, cases in Angola and the DRC are found in cities, which suggests that transmission may be occurring through an “urban yellow fever” cycle, in which the virus is transmitted between humans by means of the bite of Aedes aegypti mosquitoes, rather than the traditional “jungle yellow fever” cycle of monkey–mosquito–monkey transmission in which humans are incidental hosts. Further complicating the situation, there appears to be a separate outbreak in Uganda concurrent swith the Angola-based outbreak.

The identification in China of 11 travelers who returned from Angola with yellow fever infection is also particularly troubling, since yellow fever has never been found in Asia even though laboratory studies have demonstrated that Asian A. aegypti mosquitoes are vector-competent. The reason for the absence of yellow fever from Asia is unknown and has been a subject of much speculation.3 Although it is very worrisome that people are returning from Angola with yellow fever, it is somewhat reassuring that China manufactures 17D vaccine for the domestic market and would probably be able to control an outbreak. The importations, however, indicate that there are weaknesses in the current International Health Regulations, which require persons entering a region with potential for yellow fever outbreaks to provide evidence of immunization.

Given that we have a highly effective yellow fever vaccine that confers lifelong immunity with one dose, why is yellow fever still a problem? Much of the answer comes down to vaccine supply and demand.

The 17D vaccine is a “legacy” vaccine produced in embryonated chicken eggs using technology that has changed little since the 1940s, when the seed-lot system was introduced. Three 17D substrains (17D-204, 17DD, and 17D-213) are used as vaccines. They have minor differences in genome sequences, but all have proved to be excellent vaccines. Currently, there are only six manufacturers of yellow fever vaccine worldwide, and they collectively produce approximately 50 million to 100 million doses each year; four (Institut Pasteur, Senegal; Bio-Manguinhos/Fiocruz, Brazil; Chumakov Institute of Poliomyelitis and Viral Encephalitides, Russia; and Sanofi Pasteur, France) are “prequalified” by the WHO to distribute vaccine internationally and two (Sanofi Pasteur, United States; and Wuhan Institute of Biological Products, China) make vaccine for domestic markets. Thus, the number of producers and the manufacturing process limit the amount of vaccine available.

Furthermore, there is a requirement for a minimum amount of virus in a dose (103.0 IU) but no maximum amount per dose, and some manufacturers’ lots contain 106.5 IU per dose (over 1000 times the minimum). Although all vaccines have proved efficacious overall, the potency of the vaccines produced by the six manufacturers varies. Currently, approximately 6 million doses are kept in reserve for emergencies. That quantity is adequate for most years, but occasionally — now, for instance, or during the 2008 epidemic in South America — these reserves are insufficient to meet the demand from large outbreaks, particularly when they affect areas where yellow fever is not seen very often, as in Angola, which had gone decades without an urban outbreak.

Clearly, there is a need to increase the vaccine supply, but a number of approaches could improve the situation in the future. First, we can increase the reserve stockpile kept for emergencies. Second, regulators and the WHO could set a maximum for the amount of vaccine in a dose. Studies have shown that 3000 IU (1/50 of the quantity in a dose of at least one current vaccine)4 or less is sufficient to stimulate protective immunity. Consequently, vaccine bulk could be diluted in manufacturing freeze-dried vaccine, but studies would be needed to investigate the stability of diluted versus undiluted vaccine and the duration of protective immunity.

Relatedly, a dose-sparing approach has been suggested, in which a fraction of the current dose could be given to vaccinees once a vaccine vial had been opened. This approach would have to be evaluated carefully to ensure that vaccinees received the appropriate quantity of diluted vaccine. In addition, the vaccine is recommended for persons 9 months of age or older (6 months or older in epidemic situations), and studies would be needed to determine whether dose-sparing vaccination was equivalent in children and adults.

Similarly, some experts have suggested using intradermal immunization rather than the traditional intramuscular or subcutaneous route.5 Although that option seems promising, the limited studies that have been conducted included no comparison between intradermal and conventional subcutaneous immunization with the same dose of vaccine. Moreover, these studies have involved vaccine from only two of the six manufacturers.
A third approach is to shift manufacturing from embryonated chicken eggs to a continuous cell line. This possibility proved unsuccessful when it was investigated in the 1980s, but cell-culture technology has greatly improved in the past 30 years. Notably, Sanofi Pasteur manufactures its chimeric yellow fever 17D-dengue (Dengvaxia) and chimeric yellow fever 17D-Japanese encephalitis (Imojev) vaccines in monkey kidney Vero cells, which suggests that Vero cells could be used to manufacture 17D vaccine. Of course, the immunogenicity and safety profile of such a Vero-cell–derived vaccine would need to be compared with that of currently licensed egg-derived vaccines.

Finally, there have been no systematic studies investigating the genome sequences of wild-type yellow fever virus strains from outbreaks to elucidate the evolution of the virus and help model the potential for outbreaks. There are 40 genomic sequences of wild-type yellow fever virus isolates in GenBank, of which 12 are from Brazil and 14 from Senegal, though the virus is currently found in 44 other countries. We still have much to learn about wild-type yellow fever virus.

In the short term, there will be difficulties in ensuring that sufficient vaccine is available to fight this major public health problem, but we have the opportunity to avoid vaccine shortfalls in the future. Toward that end, the WHO periodically reviews “Recommendations to Assure the Quality, Safety and Efficacy of Live Attenuated Yellow Fever Vaccines.” Now may be the time to revisit these requirements, which were last reviewed in 2010.

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tdap vaccine

Want to Avoid Tetanus, Diphtheria, and Pertussis? Get the TDaP Vaccines

Many of us may have had a series of vaccinations as youngsters, but do you really know what they offered protection against? One of the series of vaccinations that you may likely have had is called TDaP. The term TDaP stands for tetanus, diphtheria and pertussis (aka whooping cough) and it is a combo vaccination that will help protect against the three aforementioned potentially life-threatening bacterial diseases.

People who did get this vaccine likely had it initially between the ages of 11 and 12. If you have not had the vaccine, we recommend that you contact us as soon as possible. It should be noted that infants are more at risk of life threatening complications caused by whooping cough. Pregnant mothers can get a single dose for each pregnancy to protect the newborn child against the disease.

travel vaccinationThe first two of these diseases, diphtheria and pertussis, can be spread from one individual to another via bodily secretions like cough or sneezing. The third of these, tetanus, infects a person via scratches and other wounds on the body. While due to vaccines, tetanus has become more of a rarity, it unfortunately is still commonplace in some places around the world.

Before vaccinations became more widely used, there were around 200,000 annual cases of both diphtheria and pertussis in the United States. During this time, there were also hundreds of tetanus occurrences on a yearly basis. Last year, there were 4 cases of tetanus, 3 cases of diphtheria and 3, 510 cases of pertussis or whooping cough. These are statistics that area readily available via the World Health Organization website.

These diseases can cause a number of issues such as severe coughing spells with pertussis and with diphtheria, you may experience trouble breathing, sleeping or even incontinence at times. Here at Markham Travel Health, we take your wellness very seriously and provide a variety of vaccinations in Greater Toronto Area, including TDaP. Keep in mind that there are many vaccines that require the patient to get boosters either every 5 or every ten years and TDaP is one of them. People particularly at risk for exposure to these diseases include those in healthcare and people who travel.

TDaP protects you against tetanus, diphtheria and pertussis, but there is another vaccine called TD which will only offer you protection against tetanus and diphtheria. If you were to get the TD vaccine, you would still need the booster shot every 5-10 years. It remains though a preventative measure if you run the risk of exposure to the disease called tetanus.

We encourage you to visit our clinic to find out more about how you can take control of your health and how we can aid you in achieving a healthier life! You can also find a wealth of tips and news that is health related on our website. If you have plans to go overseas, there are required and recommended vaccines that will aid you in having a healthier and safer trip no matter where your destination. Not sure what vaccines you might need before going abroad? Visit us and we will help you get the necessary immunizations bases upon the location to which you are travelling.

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chikungunya virus

Chikungunya Virus – Global Update May 2016

Travel Health Notice

ChikungunyaExternal link is a disease caused by the chikungunya virus which typically causes fever, along with an arthritis-like pain in the joints and a rash. It is spread to humans through the bite of an infected mosquito. Although caused by a different virus, the symptoms of chikungunya can appear very similar to those of dengue feverExternal link. There is no vaccine or medication that protects against chikungunya virus.

Chikungunya occurs in many regions of the world. Outbreaks of chikungunya have become increasingly frequent since local transmission was reported for the first time in the Caribbean in December 2013. Since then, local transmission of the virus has spread to many countries in neighbouring regions.

Since 2014, there has been an increase in travel-related chikungunya cases reported in Canada. The Public Health Agency of Canada recommends that travellers protect themselves from mosquito bitesExternal link when travelling to areas where chikungunya may occur.

Where is chikungunya a concern?

Chikungunya occurs in Africa, the Americas, Asia, the Caribbean and the Pacific Islands. Several countries have reported cases in individuals who have travelled to an affected area.

Some areas are currently experiencing outbreaks:

  • Caribbean and Americas: Local transmission of chikungunya has been reported on many islands of the Caribbean, countries in Central and South America and Mexico. Outbreaks in this region are ongoing with over 1.5 million suspected and confirmed cases reported since December 2013. In March 2016, Argentina reported its first chikungunya outbreak in the country. Additional information about chikungunya cases is available on the Pan American Health Organization’s websiteExternal link.
  • Oceanic Pacific Islands: Outbreaks of chikungunya are ongoing in Cook and Marshall Islands.

Recommendations

Consult a health care provider or visit a travel health clinic preferably six weeks before you travel.

Extracted from “Public Health Agency of Canada”
http://www.phac-aspc.gc.ca/tmp-pmv/notices-avis/notices-avis-eng.php?id=120

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Zika virus infection

Canadian Recommendations on the Prevention and Treatment of Zika Virus

Abstract

Background: Zika virus (ZIKV) has recently emerged as a disease of significant public health concern. Currently, a large outbreak is occurring predominantly located in the Americas. ZIKV infection is a cause of microcephaly and other congenital abnormalities and can cause post-infectious neurologic complications such as Guillain-Barré syndrome.

Objective: To review current knowledge of ZIKV infection and to provide guidance to health care professionals who provide advice to Canadians who may be impacted by ZIKV infection.

Methods: This Statement was developed by a working group of the Committee to Advise on Tropical Medicine and Travel (CATMAT). Recommendations are based on a literature review and clinical judgment.

Results: All travellers should use personal protective measures against mosquito bites including insect repellents and protection of living areas against mosquito entry. Pregnant women should avoid travel to areas designated by the Public Health Agency of Canada as being of concern because of ongoing ZIKV transmission. Women planning a pregnancy should consult with their health care provider and consider postponing travel to these areas. All other travellers may wish to consider deferring travel to designated areas based on risk tolerance, values, and preferences.

Sexual transmission of ZIKV from male partners has been documented and couples should practice abstinence or use condoms for the duration of a pregnancy, while in a risk area, or until viral shedding has likely ceased. In the absence of clear data, we make the assumption that viral shedding is unlikely to persist beyond 6 months for men and two months for non-pregnant women.

Health care providers should take a travel history from their pregnant patients including relevant information related to the travel history of their partner(s). Screening and management recommendations are provided for all travellers including potentially contagious male partners, pregnant women (symptomatic and asymptomatic), and the fetus or infant of potentially infected women. There is no specific antiviral therapy for the treatment of ZIKV infection.

Conclusion: Robust quantitative assessments for the full spectrum of ZIKV-associated risks are not possible. This reflects, among other things, uncertainties related to the likelihood of infection among travellers to ZIKV-affected areas, vertical transmission from mother to fetus, sexual transmission (from symptomatic or asymptomatic partners), and serious ZIKV-associated sequelae among travellers. Given this uncertainty, as well as the potentially severe effects of ZIKV infection on the fetus, recommendations are conservative. CATMAT will update its recommendations as new information becomes available.

Suggested citation: Zika Working Group on behalf of the Committee to Advise on Tropical Medicine and Travel (CATMAT). Canadian Recommendations on the Prevention and Treatment of Zika virus: Update. Can Comm Dis Rep 2016;42:101-11.

Introduction

Zika virus (ZIKV) infection is caused by a flavivirus transmitted through the bite of an infected Aedes mosquito, mainly Aedes aegypti. Aedes albopictus has also been associated with transmission of ZIKV Footnote3. Although infections in humans were documented in the 1950s, ZIKV has only recently emerged as a disease of significant public health concern. Currently, there is a large outbreak underway in the Americas with transmission also occurring in some other countries. Outbreaks have also recently occurred on islands in the South Pacific and in Cabo Verde. Before this, known areas of endemic transmission were limited to Asia and Africa, and transmission rates in these areas are generally low. It is likely that the virus will continue to spread because the mosquito vectors are found in many tropical and subtropical regions and in some warmer temperate regions Footnote4,Footnote5.

A major concern with the current outbreak is the spatial and temporal clustering of ZIKV activity with an increase in the incidence of children born with microcephaly, defined as a head circumference measurement below the third percentile and disproportionate to the weight and length percentile measurements Footnote6,Footnote7. A recent epidemiologic study also demonstrated a strong association of ZIKV and microcephaly in the population of French Polynesia, where an outbreak took place from 2013-2015 Footnote8. The role of ZIKV in microcephaly is further supported by detection of ZIKV viral genome in amniotic fluid, placenta and tissues of affected fetuses and neonates Footnote1,Footnote9, and the pattern of microcephaly associated with ZIKV appears to be within the context of a broader syndrome that may be distinct from that caused by other fetal insults Footnote9. Based on the available evidence, a causal relationship between prenatal ZIKV infection and infant microcephaly or other severe brain anomalies has been acknowledged in the scientific community Footnote10.

Although disease is usually mild in adults, ZIKV infection can cause neurologic sequelae such as Guillain-Barré syndrome (GBS) Footnote7,Footnote11. A recent case control study done in French Polynesia estimates a 0.24 in 1000 risk for developing GBS in persons infected with ZIKV. This is comparable to the risk of 0.25 to 0.65/1000 observed following Campylobacter jejuni infection. There are also reports of acute disseminated encephalomyelitis (ADEM) following ZIKV infection Footnote12.

Finally, there are multiple reports of sexual transmission of ZIKV from infected males to their partner(s), including male-to-male Footnote2,Footnote13,Footnote14,Footnote15,Footnote16, suggesting that this event is not a rare occurrence.

The purposes of this statement are to review our current knowledge of ZIKV infection and to provide guidelines for health care providers on prevention and management of ZIKV disease.

Methods

This statement was developed by a working group of the Committee to Advise on Tropical Medicine and Travel (CATMAT). Members of the working group were from CATMAT, the Public Health Agency of Canada (the Agency) and the Society of Obstetricians and Gynaecologists of Canada. Each member was a volunteer, and none declared a relevant conflict of interest. This guideline complements existing CATMAT statements including the Statement on Personal Protective Measures to Prevent Arthropod bites Footnote17 and the Statement on Pregnancy and Travel Footnote18. A literature search for evidence related to ZIKV was conducted. Guidelines and reports from international and national public health organizations including, but not limited to, the Centers for Disease Control in the United States, the Pan American Health Organization and the World Health Organization, were also retrieved and reviewed.

Epidemiology

ZIKV was first isolated from monkeys in Uganda in 1947. Soon after (1952), human infections were detected in Uganda and Tanzania Footnote19,Footnote20. However, human infections were rarely reported until 2007, when the first major outbreak of ZIKV disease occurred on the island of Yap (Micronesia) in the southwestern Pacific Ocean Footnote21. Between 2013 and 2015, additional outbreaks occurred on islands and archipelagos from the Pacific region including a large outbreak in French Polynesia Footnote22,Footnote23 and another in Cabo Verde Footnote24. In 2014, local transmission in the Americas was reported for the first time on Easter Island Footnote25. ZIKV has since spread to a wide region of the Americas including, at the time of updating, more than 43 countries and territories. It is anticipated that ZIKV will continue to spread through the Americas, in particular in tropical and subtropical regions Footnote27,Footnote28.

Transmission

The mosquitoes associated with ZIKV can be active during the day and night, with biting activity often peaking in the morning and later in the afternoon. In vertebrate hosts, the incubation period is usually three to 12 days, with blood viremia (the period when ZIKV is present in the blood) usually lasting for three to five days Footnote29,Footnote30. Viremia has typically been detected only during symptoms, although a case of prolonged viremia during pregnancy has been reported Footnote31. It is uncertain whether viremia is detectable prior to symptoms, or during asymptomatic infection. If bitten by a competent mosquito while viremic, the human (or other) host can infect the mosquito thereby completing the transmission cycle Footnote28. Vertical transmission between mother and developing fetus also presumably occurs during this viremic period Footnote32,Footnote33. Other described routes of transmission include blood product transfusion Footnote34 and sexual transmission from men after symptomatic infection Footnote13,Footnote14,Footnote15,Footnote16. Viral RNA has been detected in the semen of males previously known to have symptomatic disease at very high levels; how long this persists, and whether it can occur in males who were infected but asymptomatic is not known. Viral RNA has also been detected in saliva Footnote23 or urine Footnote35,Footnote36 more than a week after clearance of blood viremia. Neutralizing antibodies for ZIKV are detectable after infection, and by extrapolation from other flaviviruses, post-infection immunity is presumed to be long lasting.

Sexual transmission of ZIKV from infected women to their sexual partners and from persons who are asymptomatically infected has not been reported; however, there is insufficient evidence to exclude these as routes of transmission.

ZIKV RNA has been detected in breast milk; however, there have not been any documented reports of transmission to infants through breastfeeding Footnote19. At this time, the World Health Organization (WHO) considers that “the benefits of breastfeeding for the infant and mother outweigh any potential risk of Zika virus transmission through breast milk” Footnote37. CATMAT shares this opinion.

Clinical Manifestations

Approximately 20-25% of persons infected with ZIKV will manifest symptoms, including fever, myalgia, pruritis, eye pain, and maculopapular rash Footnote21,Footnote38. Early clinical manifestations are generally similar to other arboviral infections including dengue and chikungunya Footnote38,Footnote39. Thus, the differential diagnosis of a febrile returned traveller from the Americas will likely include these arboviral entities, as well as malaria Footnote40 and other viral infections Footnote41,Footnote42.

Post-infection neurologic complications, such as Guillain-Barré synfrome (GBS), have been reported from many of the countries affected by the current ZIKV outbreak Footnote11,Footnote30,Footnote43,Footnote44. They include French Polynesia where a case-control study estimated that the odds of positive ZIKV serology was substantially greater in GBS cases compared to matched controls (OR 59.7; 95% CI 10.4 to ∞) Footnote45. In this same study, and based on a ZIKV population seroprevalence of 0.66, the risk of GBS following ZIKV infection was estimated at approximately 1/4,000. Other neurological manifestations have also been reported in association with ZIKV infection, e.g., acute myelitis, meningoencephalitis, and acute disseminated encephalomyelitis Footnote12,Footnote46,Footnote47, suggesting that the neurological spectrum of sequelae associated with ZIKV may be broader than previously thought.

Clinically relevant thrombocytopenia and subcutaneous hematomas have been reported in a small number of cases Footnote48,Footnote49. Deaths from other causes have also been reported Footnote50,Footnote51.

Brazil, French Polynesia and several other affected countries (e.g., Colombia) Footnote7 have reported infant microcephaly associated with ZIKV infection. Ocular abnormalities and other congenital malformations such as arthrogryposis and hydrops fetalis have also been described Footnote52,Footnote53,Footnote54. Although the full impact of ZIKV infection during pregnancy remains to be described, there is now consensus that infection can cause fetal congenital anomalies Footnote8,Footnote10. Although the likelihood of serious fetal harm following infection is unknown there is evidence to suggest that it is not a rare occurrence. For example, a recent case series from Brazil suggests that infection is associated with serious outcomes including fetal death, placental insufficiency, fetal growth restriction, and central nervous system (CNS) injury (12/42 ZIKV-infected females on whom Doppler ultrasonography was performed) Footnote55. A retrospective study of patients in French Polynesia suggested that the impact of ZIKV was primarily through infections occurring during the first trimester (when it was estimated to result in an approximately 1% risk of microcephaly) Footnote8.

Reviews of the epidemiology of ZIKV, as well as the causal association of ZIKV and microcephaly have been recently published Footnote10.

Risk to travellers

The Agency has published an assessment of the risk of ZIKV to Canadians Footnote56. It concludes:

  • For most infected travellers, ZIKV will have little or no health impact (Low impact, with medium confidence). However, severe outcomes (e.g., GBS) might occur in some affected individuals (High impact, medium confidence).
  • There could be Very High impact (with medium confidence) to the unborn children of women who become infected with ZIKV while pregnant.
  • Sexual transmission, from symptomatic male travellers to a sexual partner(s) who has(ve) not travelled, has been reported. Because the likelihood of infection with ZIKV is considered low, so too is the likelihood of transmission via this route (Low likelihood, medium confidence). However, if a man becomes infected with ZIKV, the likelihood of transmission to his sexual partner(s) is assessed as Medium (low confidence).

This assessment also considered factors that might affect the likelihood or impact of ZIKV infection. While evidence is very limited in this regard, several plausible relationships were identified:

  • Conditions at higher elevations (≥ 2,000 m) are generally not supportive of viral replication in, or survival of,Aedes aegypti populations. Correspondingly, the relative likelihood of infection with ZIKV might be substantially lower for travellers (depending on how much time they spend at higher compared to lower elevations) to such areas.
  • All else held equal, the likelihood of infection is higher in countries/areas that are reporting high levels of ZIKV activity compared to those that are not.
  • The likelihood of infection is likely lower for shorter travel durations and/or when staying in protected environments (e.g., well screened and air-conditioned accommodations, transiting through an airport in a risk area). This might also apply to situations where the traveller is staying in an isolated location, i.e. where there are relatively few residents who might support sustained transmission.

CATMAT stresses that, at this time, robust quantitative assessments for the full spectrum of ZIKV-associated risks are not possible. This reflects, among other things, uncertainties related to: the likelihood that travellers will be infected with ZIKV, the likelihood that travellers infected with ZIKV will manifest serious sequelae like GBS, and the probability that maternal infection during pregnancy will lead to fetal infection. Given this uncertainty, as well as the potentially severe effects of ZIKV infection on the fetus, our recommendations are conservative. However, we also realize that there might be circumstances where a patient is unable to or unsure about whether to adhere to our guidance. In this situation, we believe it is appropriate to consider factors such as those identified above to help inform the decision-making process (also see below, decision to travel to risk areas).

Areas of risk

There is widespread transmission over much of South and Central America, the Caribbean, but not temperate areas of Argentina and Chile. An up to date list of countries to which our recommendations apply is maintained by the Agency.

There are areas of Africa and Asia where ZIKV transmission has previously occurred, or is considered endemic with very low potential for transmission to travellers. These are not currently designated as risk areas by the Agency, nor are countries/territories where ZIKV has been reported, but only in travellers and/or as a result of sexual transmission.

Prevention – Decision to travel to areas of risk

All travellers

Health care providers should discuss with travellers what is known and what is not known about ZIKV to help their patients make an informed choice about travel based on this guideline and the ZIKV information on theGovernment of Canada’s ZIKV webpage. Factors to consider include:

  • The possibility of serious sequelae such as post-infection neurologic complications (e.g., GBS, ADEM).
  • The potential for ZIKV infection during pregnancy to have a severe impact of the fetus.
  • The potential for sexual transmission from men to their sexual partners, which is particularly relevant to couples who are actively trying to conceive.
  • The potential for co-morbidities to predispose to more serious outcomes (there is little specific evidence in this regard, though it is reasonable to expect such impacts).
  • Patients’ values and preferences (including risk perception and risk tolerance).
  • The potential impacts of following the recommendation on a couple’s reproductive plans.
  • The large uncertainties that continue to hamper the development of robust risk assessments for Canadians.
  • Itinerary- specific factors (see section on risk to Canadian travellers) that might affect the likelihood of being exposed to ZIKV.
Pregnant women and women who are planning a pregnancy

CATMAT recommends that pregnant women avoid travel to areas of risk. Women planning a pregnancy should consult with their health care provider and consider postponing travel to areas of risk as defined above. Pregnant women and those planning a pregnancy who choose to travel to areas of risk or for whom travel cannot be avoided are strongly advised to use Personal Protective Measures (PPM) against insect bites (see below for more detail). As for travellers generally (see previous section), health care providers should help their patients make an informed decision regarding travel or other aspects of ZIKV prevention. The risk of severe adverse outcomes of pregnancy deserves particular emphasis.

Prevention of mosquito-borne transmission

There is no vaccine or immunoprophylaxis that protects against ZIKV infection. CATMAT recommends that all travellers to areas of risk should be advised to strictly adhere to recommendations for the use of personal protective measures against mosquito bites (see below). Because the mosquitoes that transmit ZIKV can bite at any time (including during daylight hours), PPM should be used through all hours of the day and night. In addition to ZIKV, PPM provide protection against other vector-associated diseases such as malaria, dengue, and chikungunya. Recommendations for PPM can be found in CATMAT’s Statement on Personal Protective Measures to Prevent Arthropod Bites Footnote17. These are summarized below:

Personal protective measures to prevent arthropod bites

1) Cover up:

  • Wear light-coloured, long-sleeved, loose fitting, tucked-in shirts, long pants, shoes or boots (not sandals), and a hat.

2) Use insect repellent on exposed skin:

  • It is recommended that adults use repellents that contain DEET (20-30%) or icaridin (20%).
  • It is recommended that children six months to twelve years of age use repellents that contain icaridin (20%). As a second choice, this age group can use repellents with age-appropriate DEET concentrations as per label. Since publication of the PPM guidelines, p-Menthane-3,8-diol 20% has become available in Canada and is an option.
  • If bites cannot be avoided using a physical barrier, consider use of up to 10% DEET or 10% icaridin for infants under six months of age.

3) Protect living areas from mosquito entry:

  • Stay in a well-screened or completely enclosed air-conditioned room.
  • Reduce your risk in work and accommodation areas by closing eaves, eliminating holes in roofs and walls and closing any other gaps.

4) If mosquito entry into living quarters cannot be otherwise prevented (e.g. by screening):

  • Use a bed net (e.g. for sleeping or resting inside), preferably treated with insecticide.
  • Netting can also be used to protect children in playpens, cribs, or strollers.
  • Bed nets will also provide protection against diseases like malaria.

5) Apply a permethrin insecticide to clothing and other travel gear for greater protection:

  • Although permethrin clothing treatments are not widely available in Canada, travel health clinics can advise you how to purchase permethrin and pre-treated gear before or during your trip.
  • Permethrin-treated clothing is effective through several washes.
  • Always follow label instructions when using permethrin.
  • Do not use permethrin directly on skin.

Insect repellents, insecticide treated bed nets and permethrin treated clothing/clothing treatments have been reviewed for safety in Canada and/or the United States. They are considered safe, including for children, pregnant and breastfeeding women if used in accordance with label directions.

Prevention of sexual transmission

ZIKV RNA has been detected in semen two months after acute illness Footnote16,Footnote57. It is not known how long viral shedding in semen can last, how often this might happen when infection is asymptomatic, or how easily virus can be transmitted by sexual contact. The number of reports of sexual transmission has been increasing, suggesting this may not be a rare occurrence. When properly used, condoms should minimize the risk of sexual transmission.

Pregnant women and their male partner

If travel to a risk area is unavoidable, pregnant woman and male partners should practise abstinence or use condoms until more is known about the prolonged viral shedding of ZIKV in semen. If the male partner of pregnant female has been in a risk area the couple should practice abstinence or use condoms for the full duration of the pregnancy (including after return).

Couples planning a pregnancy

Based on current information on the incubation period and duration of viremia, and the unclear duration of viral persistence in tissues, women planning a pregnancy should wait at least two months after their return from an area of risk before trying to conceive. For couples where the male partner has travelled in an area of risk, it is reasonable to delay trying to conceive for six months.

Couples outside the context of current or planned pregnancy

Men who have returned from a risk area and who wish to reduce the possibility of sexual transmission to their partner (outside of the context of pregnancy) can do so through appropriate use of condoms. Although transmission has so far only been reported after symptomatic infection, and it is plausible that the risk after asymptomatic infection is lower, there are no data to support making different recommendations for symptomatic or asymptomatic men. Use of condoms likely provides the greatest protection in the first weeks following illness, but given the potential for long-term persistence in semen, condom use should be considered for six months after return from a risk area.

Role of laboratory testing in transmission prevention or monitoring of pregnant women

Laboratory testing for ZIKV infection is fully described below. In theory, based on information from other similar viral infections, the absence of ZIKV-specific antibodies two weeks or more after the last possible exposure implies that the individual has never been infected, and is not contagious to sexual partners or to the fetus. Such seronegative individuals could consider discontinuing measures to intensively follow the pregnancy for ZIKV-related complications, as well as measures to prevent sexual transmission. The absence of ZIKV RNA in a semen sample might indicate absence of contagiousness, but there are no data to support this practice at this time, and there remains the theoretical risk of poor test sensitivity for some ZIKV strains. However, at this time, serology and RNA testing in Canada is only available for symptomatic individuals and pregnant women. Testing of asymptomatic individuals (men or non-pregnant women) is not routinely offered.

Laboratory Diagnosis

Molecular testing using reverse-transcriptase PCR (RT-PCR) is conducted by some provincial laboratories in Canada. The National Microbiology Laboratory provides provincial support, along with confirmatory testing. Sensitivity and specificity are unknown, but presumed to be high, at least in the initial few days of illness, since ZIKV appears to circulate in the blood for the first three to five days after onset of symptoms Footnote27. ZIKV RNA may be present in urine for a few days after it is no longer detectable in blood Footnote27,Footnote58. Information about the National Microbiology Laboratory guidelines and testing recommendations are available on the Government of Canada’s website.

At the National Microbiology Laboratory, serologic testing is currently performed using a Centers for Disease Control in the United States based in-house IgM enzyme linked immunosorbent assay (ELISA) followed by a confirmatory ZIKV plaque reduction neutralization test (PRNT) Footnote36. Antibodies appear approximately five to six days after onset of symptoms Footnote30. For the acutely unwell patient with less than 10 days of symptoms, both RT-PCR and serology should be requested to maximize sensitivity. For the convalescent patient with symptom onset over 10 days ago, only serology should be requested. Appropriate diagnostic specimens for RT-PCR testing include plasma/serum, urine, cerebrospinal fluid (CSF), amniotic fluid and placental tissue. Serology is usually only performed on serum; however, viral antibodies may be detected in CSF in some cases of neurological disease.

As ZIKV is a member of the flaviviridae, serologic tests, including the IgM ELISA, may be cross-reactive with other flaviviruses such as dengue, West Nile, and Yellow Fever (including among vaccine recipients) Footnote4. Confirmation of ZIKV therefore rests on amplification of viral RNA by RT-PCR, or by confirmatory PRNT serologic testing. Confirmatory testing generally requires neutralizing IgG production, which may appear later than IgM. The specificity of the IgM ELISA is limited particularly during secondary flavivirus infections. Patients whose serum samples are IgM positive and have ZIKV-specific antibodies confirmed through PRNT are confirmed cases of viral infection. However, it is also recommended for equivocal cases that acute and convalescent sera be collected 2-3 weeks apart to document a seroconversion or a diagnostic increase (four-fold or greater) in virus specific neutralizing antibodies. This is because individuals previously infected with or vaccinated against flaviviruses may exhibit cross reactivity in PRNT tests making them difficult to interpret.

PCR for ZIKV can be performed on amniotic fluid (when amniocentesis is technically feasible) to confirm infection of the fetus. At this time, the risk of adverse outcomes of pregnancy if the fetus is infected with ZIKV is unknown, so the risk of the procedure must be weighed against the clinical utility of this test result. A negative PCR result likely means that the fetus is not currently infected, but would not eliminate the possibility of previous infection. It is not known when ZIKV RNA would be expected to appear in amniotic fluid after infection, or how long it is likely to be detectable. There is some evidence that viral RNA may persist in amniotic fluid for monthsFootnote59.

For postnatal diagnosis of congenital infection, PCR for ZIKV can be performed on placental tissue, umbilical cord blood or infant blood, and CSF for confirmation of congenital infection. It is possible, however, that infants or fetuses infected weeks prior to specimen sampling will no longer have detectable viral RNA.

Screening and Management

Evaluation of non-pregnant travellers returning from endemic countries

Testing for ZIKV infection (PCR) should be considered in the diagnosis of any ill traveller with compatible epidemiologic and clinical history, when symptom onset is within three days after arrival in, to 14 days after departing from an area of risk. Testing for other similar viral infections and for malaria should also be done as appropriate.

Serologic testing may be considered for male returned travellers whose clinically compatible illness has resolved, and are at least two weeks post exposure, in order to assess for potential contagiousness to sexual partners. The same would theoretically apply to males who have travelled and remain asymptomatic but testing is not currently being offered to this group in Canada. Testing an asymptomatic individual simply out of curiosity concerning their serostatus would not be a prudent use of limited resources. Given that neurologic disorders like GBS have occurred following ZIKV infection, returning travellers should be counselled to report any neurologic symptoms to their doctor. In the event of the diagnosis of GBS or other unusual neurologic syndrome, a travel history for the patient and any male sexual partners should be elicited. If ZIKV infection is thought to be potentially associated with the illness, a specialist should be consulted.

Evaluation in the context of pregnancy
Evaluation of pregnant women with a travel history to an area of risk

Health care providers should take a travel history from their pregnant patients including relevant information related to the travel history of their partner(s). Any patient who indicates that they or their partner have recently travelled to an area of risk should be further evaluated.

Screening of asymptomatic pregnant women should be discussed on a case-by-case basis between the woman and her health care provider. Screening would consist of serology at least two weeks after the last potential exposure, as well as fetal ultrasounds, at a frequency to be determined in consultation with the woman’s obstetrician, at least until serology is shown to be negative. The usefulness of serology will depend partly on the turn-around time for results, which can be discussed with the local laboratory. The decision to test should include consideration of how the results of the screening tests would be used to inform subsequent decisions. Diagnosis and identification of poor fetal outcomes will allow for appropriate counselling.

Pregnant women and their partners may be justifiably concerned about the risk of ZIKV infection to their fetus and may want to receive counselling to decide the best course of action, including the question of termination. The risk of vertical infection (with clinical sequelae) in the setting of symptomatic or asymptomatic maternal infection in a given trimester of pregnancy is unknown, but appears highest in the first trimester Footnote8. However severe sequelae have been reported after infection at all stages of pregnancy Footnote55. This uncertainty makes pregnancy counselling a difficult prospect. Regardless, discussion and informed decision making regarding options for management of ZIKV infection in pregnancy (much like any other congenital infection or congenital anomaly) requires thorough consultation with a Maternal Fetal Medicine Specialist or another specialist familiar with reproductive infectious diseases. As understanding of the risks of ZIKV infection in pregnancy becomes clearer, so too will the related counselling messages, which in turn will allow each patient to make her own individual decision about her pregnancy.

Evaluation of pregnant women with symptoms compatible with ZIKV infection

Testing (including PCR) should be offered to pregnant women with acute signs and symptoms compatible with ZIKV. As described above, for the acutely unwell patient with less than 10 days of symptoms, both RT-PCR and serology should be requested to maximize sensitivity. For the convalescent patient with symptom onset over 10 days ago, only serology should be requested. Repeated ultrasound monitoring is indicated, unless the woman is found to be negative on laboratory testing. A woman whose fetus is suspected of having a congenital anomaly should also be offered testing if she or her partner has travelled to any location where ZIKV transmission may be occurring, even at a low level.

The risk of microcephaly or other adverse pregnancy outcomes for a woman known to be infected with ZIKV cannot be estimated from currently available data. Although measurements of head circumference and biparietal diameter may occur as early as 15 weeks, there is no defined gestational age by which microcephaly can be ruled out. Serial monitoring by ultrasound with close attention to measurement trends over time is recommended.  It is possible that changes in intracranial anatomy may not be elucidated until well into the third trimester, or later.

Evaluation of the fetus among pregnant women diagnosed with ZIKV infection

Serial ultrasounds (every 3-4 weeks) are recommended in pregnant women with confirmed or suspected (if testing results are pending) ZIKV infection in pregnancy, and for asymptomatic pregnant travellers returning from areas of risk while awaiting diagnosis, to help define risk and counsel the mother. Should CNS calcifications or fetal microcephaly be noted at ultrasonography of the asymptomatic pregnant returned traveller, then specific ZIKV testing of the fetus (e.g., amniocentesis) should be considered to help define the likely cause of the anomaly.

Evaluation of the infant born to a woman diagnosed with ZIKV infection or with suspected congenital ZIKV infection

Infants born to women with confirmed or suspected ZIKV infection in pregnancy, or those with microcephaly, intracranial calcifications or other symptoms of congenital ZIKV infection in whom the mother had potential exposure to the virus, should be tested. This testing should include serology, PCR of serum (umbilical cord or infant sample), and PCR of placenta; if CSF is sampled, this can also be sent for PCR and serology. Infants with suspected or confirmed congenital ZIKV infection should also undergo further work-up including: routine lab tests (CBC and liver enzymes), head ultrasound, ophthalmologic examination, and hearing evaluation. Infants with confirmed congenital ZIKV infection should have neurodevelopmental monitoring throughout infancy to assess the potential for long term sequelae.

Infants born to women with symptoms of active ZIKV infection around the time of delivery are at risk for perinatal transmission of the disease. In the limited number of reported cases to date, perinatally infected infants have exhibited either no or mild symptoms and laboratory findings (rash, thrombocytopenia) Footnote32. Regardless, such infants should be monitored closely given the unclear spectrum of potential illness in this emerging infection. Testing with serology and serum PCR during acute illness is recommended. In such cases, care should be taken to ensure a thorough work up for other important and treatable causes of congenital infections, such as cytomegalovirus and toxoplasma.

Treatment

Currently there is no specific antiviral therapy for the treatment of ZIKV infection. Treatment is supportive with antipyretics (acetaminophen in pregnancy), hydration and rest. Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided until dengue can be ruled out to reduce the risk of hemorrhage Footnote60. Symptomatic disease typically lasts for up to seven days. Urgent medical care is recommended for any symptoms associated with GBS, and treating health care providers should be made aware of recent travel to area with ZIKV circulation and/or symptoms of ZIKV infection.

If ZIKV infection is confirmed in the setting of pregnancy, referral to a Maternal Fetal Medicine Specialist or specialist familiar with Reproductive Infectious Diseases should be made. If microcephaly, intracranial calcifications or other abnormalities are identified, appropriate counselling by a Neonatologist and Pediatric Infectious Diseases Specialist on potential neurodevelopmental outcome should be offered to parents.

Recommendations for ZIKV
Action Group Recommendation
Decision to travel to areas of risk All travellers Health care providers should discuss current knowledge about ZIKV, associated risks, and preferences and values with patients. Some travellers may wish to postpone travel to areas of risk.
Pregnant women Pregnant women should avoid travel to areas of risk.
Women planning a pregnancy Women planning a pregnancy should consider postponing travel to areas of risk.
Prevention of mosquito borne transmission All travellers All travellers to areas of risk should strictly adhere to recommendations for the use of personal protective measures against mosquito bites through all hours of the day and night.
Prevention of sexual transmission Pregnant women and their male partner Couples should practise abstinence or use condoms while in a risk area and for the duration of the pregnancy.
Couples planning a pregnancy Women planning a pregnancy should wait at least two months after their return from an area of risk before trying to conceive.

Male partners who have travelled in an area of risk should delay trying to conceive for six months after their return.

Couples outside the context of current or planned pregnancy Male partners who have travelled in an area of risk should consider using condoms for six months after their return.
Screening and Management All travellers Testing should be considered for any ill traveller with compatible epidemiologic and clinical history, when symptom onset is within three days after arrival in, to 14 days after departing from an area of risk.

Serology and RNA testing in Canada is only available for symptomatic individuals and pregnant women. Testing of asymptomatic individuals (men or non-pregnant women) is not routinely offered.

Acutely unwell patient with less than 10 days of symptoms, both RT-PCR and serology should be requested to maximize sensitivity.
Convalescent patient with symptom onset over 10 days ago, only serology should be requested.
Male partners Serologic testing may be considered for male returned travellers whose clinically compatible illness has resolved, and are at least two weeks post exposure, in order to assess for potential contagiousness to sexual partners.
All pregnant women All pregnant patients with a travel history to an area of risk should have further evaluation.
Asymptomatic pregnant women Asymptomatic pregnant women should consider testing; this would consist of serology at least two weeks after the last potential exposure and fetal ultrasounds, (unless found to be seronegative) at a frequency to be determined in consultation with the woman’s obstetrician.
Symptomatic pregnant women Acutely unwell patient with less than 10 days of symptoms, both RT-PCR and serology should be requested to maximize sensitivity.
Convalescent patient with symptom onset over 10 days ago, only serology should be requested.

Repeated ultrasound monitoring is indicated, unless the woman is found to be negative on laboratory testing.

Fetus of pregnant women with confirmed or suspected ZIKV infection Pregnant women with confirmed or suspected ZIKV infection in pregnancy should receive serial ultrasounds (every 3-4 weeks).

 

Infant born to a woman with confirmed or suspected ZIKV infection or with suspected congenital ZIKV infection Infants born to women with confirmed or suspected ZIKV infection in pregnancy, or those with microcephaly, intracranial calcifications or other symptoms of congenital ZIKV infection in whom the mother had potential exposure to the virus, should be tested.

This testing should include serology, PCR of serum (umbilical cord or infant sample), and PCR of placenta; if CSF is sampled, this can also be sent for PCR and serology.

Infants with suspected or confirmed congenital ZIKV infection Infants with suspected or confirmed congenital ZIKV infection should also undergo further work-up including routine lab tests (CBC and liver enzymes), head ultrasound, ophthalmologic examination, and hearing evaluation.

Those with confirmed infection should have neurodevelopmental monitoring throughout infancy to assess the potential for long term sequelae.

Treatment Pregnant cases Acetaminophen, hydration, and rest. Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided until dengue can be ruled out. Urgent medical care is recommended for any symptoms associated with GBS or other neurologic syndromes. Referral to a maternal fetal medicine specialist or infectious diseases specialist should be made. If fetal abnormalities are identified, appropriate counselling should be offered.
Non-pregnant cases Antipyretics, hydration, and rest. Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided until dengue can be ruled out. Urgent medical care is recommended for any symptoms associated with GBS or other neurologic syndromes.

Additional resources and useful links:

Acknowledgements

This statement was developed by the Zika Working Group: Libman M (chair), Boggild A, Bui Y, Brophy J, Drebot M, Geduld J, McCarthy A, Safronetz D, Schofield S, Tataryn J, Vanschalkwyk J, Yudin M.

CATMAT acknowledges and appreciates the contribution of Alex Demarsh and Tanya Christidis to the statement.

CATMAT members: McCarthy A (Chair), Acharya A, Boggild A, Brophy J, Bui Y, Crockett M, Greenaway C, Libman M, Teitelbaum P and Vaughan S.

Liaison members: Audcent T (Canadian Paediatric Society), Gershman M (United States Centers for Disease Control and Prevention) and Pernica J (Association of Medical Microbiology and Infectious Disease Canada).

Ex officio members: Marion D (Canadian Forces Health Services Centre, Department of National Defence), McDonald P (Division of Anti-Infective Drugs, Health Canada) and Schofield S (Pest Management Entomology, Department of National Defence).

Conflict of interest

None declared.

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Mécharles S, Herrmann C, Poullain P, Tran T, Deschamps N, Mathon G, et al. Acute myelitis due to Zika virus infection. Lancet 2016;ePub.
Footnote47
Carteaux G, Maquart M, Bedet A, Contou D, Brugières P, Fourati S, et al. Zika Virus Associated with Meningoencephalitis. N Engl J Med 2016;ePub.
Footnote48
Karimi O, Goorhuis A, Schinkel J, Codrington J, Vreden SGS, Vermaat JS, et al. Thrombocytopenia and subcutaneous bleedings in a patient with Zika virus infection. Lancet 2016;387:939-940.
Footnote49
Zammarchi L, Stella G, Mantella A, Bartolozzi D, Tappe D, Günther S, et al. Zika virus infections imported to Italy: clinical, immunological and virological findings, and public health implications. J Clin Virol 2015;63:32-35.
Footnote50
Baud D, Van Mieghem T, Musso D, Truttmann AC, Panchaud A, Vouga M. Clinical management of pregnant women exposed to Zika virus. Lancet Infect Dis ;16(5):523.
Footnote51
Arzuza-Ortega L, Pérez-Tatis G, López-García H. Fatal Zika virus infection in girl with sickle cell disease, Colombia. Emerging Infect Dis 2016;22(5).
Footnote52
Ventura CV, Maia M, Bravo-Filho V, Góis AL, Belfort R. Zika virus in Brazil and macular atrophy in a child with microcephaly. Lancet 2016;387(10015):228.
Footnote53
Costa F, Sarno M, Khouri R, de Paulo Freitas B, Siqueira I, Ribeiro GS, et al. Emergence of Congenital Zika Syndrome: Viewpoint From the Front Lines. Ann Intern Med 2016;ePub.
Footnote54
Sarno M, Sacramento GA, Khouri R, do Rosário MS, Costa F, Archanjo G, et al. Zika Virus Infection and Stillbirths: A Case of Hydrops Fetalis, Hydranencephaly and Fetal Demise. PLOS Negl Trop Dis 2016;10(2):e0004517.
Footnote55
Brasil P, Pereira J,Jose P., Raja Gabaglia C, Damasceno L, Wakimoto M, Ribeiro Nogueira RM, et al. Zika Virus Infection in Pregnant Women in Rio de Janeiro — Preliminary Report. N Engl J Med 2016;ePub.
Footnote56
Public Health Agency of Canada. Rapid Risk Assessment: The risk of Zika virus to Canadians. 2016; Available at: http://healthycanadians.gc.ca/publications/diseases-conditions-maladies-affections/risks-zika-virus-risques/index-eng.php. Accessed March 3, 2016.
Footnote57
Atkinson B, Hearn P, Afrough B, Lumley S, Carter D, Aarons E. Detection of Zika virus in semen. Emerging Infect Dis 2016;22(5).
Footnote58
Centers for Disease Control and Prevention (CDC). Revised diagnostic testing for Zika, chikungunya, and dengue viruses in US Public Health Laboratories. 2016; Available at: http://www.cdc.gov/zika/pdfs/denvchikvzikv-testing-algorithm.pdf. Accessed March 3, 2016.
Footnote59
Calvet G, Aguiar RS, Melo AS, Sampaio SA, de Filippis I, Fabri A, et al. Detection and sequencing of Zika virus from amniotic fluid of fetuses with microcephaly in Brazil: a case study. Lancet Infect Dis 2016;ePub.
Footnote60
Centers for Disease Control and Prevention (CDC). Clinical Evaluation & Disease. 2016; Available at: http://www.cdc.gov/zika/hc-providers/clinicalevaluation.html. Accessed Feb. 5, 2016.

Extracted from “Public Health Agency of Canada”
http://phac-aspc.gc.ca/publicat/ccdr-rmtc/16vol42/dr-rm42-5/ar-01-eng.php

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Zika virus infection

Zika virus infection: Global Update

Travel Health Notice

Zika virus infectionExternal link is caused by a virus which is primarily spread by the bite of an infected mosquito. It can also be transmitted by an infected pregnant woman to her developing baby and sexually transmitted by an infected man to his partner. Symptoms can include fever, headache, conjunctivitis (pink eye) and skin rash, along with joint and muscle pain. The illness is typically mild and lasts only a few days and the majority of those infected do not have symptoms. There is no vaccine or medication that protects against Zika virus infection.

Zika virus is occurring in many regions of the world. Local transmission of Zika virus was first reported in the Americas in 2015. Currently there is ongoing local transmission in many countries of South Asia, Western Pacific Islands, and South and Central America, including the Caribbean, and Mexico.

In addition, Brazil has reported a significant increase in the number of newborns with microcephaly (abnormally small head) and a number of countries have reported an increase in the number of cases of Guillain-Barre SyndromeExternal link, a neurological disorder. Experts now agree that Zika virus infection causes both of these disorders.

There have been travel-related cases of Zika virus reported in Canada in returned travellers from countries with ongoing Zika virus outbreaks.

On March 8, 2016 the World Health Organization declared that the clusters of microcephaly cases and other neurological disorders, continues to constitute aPublic Health Emergency of International ConcernExternal link.

The Public Health Agency of Canada recommends that pregnant women and those planning a pregnancy avoid travel to countries with ongoing Zika virus outbreaksExternal link. All travellers should protect themselves from mosquito bitesExternal link. For additional recommendations please see the section below.

For the latest updates on countries affected by Zika virus, please visit the Public Health Agency of Canada’s list of countries with reported locally acquired Zika virusExternal link.

This travel health notice will be updated as more information becomes available.

Recommendations

Consult a health care provider or visit a travel health clinic preferably six weeks before you travel.

  • Pregnant women and those planning a pregnancy should avoid travel to countries with ongoing Zika virus outbreaks.
    • If travel cannot be avoided or postponed strict mosquito bite prevention measures should be followed due to the association between Zika virus infection and increased risk of serious health effects on their unborn baby.
  • Travellers returning from countries with ongoing Zika virus outbreaks:
    • For pregnant women, if you develop symptoms that could be consistent with Zika virus infection, you should consult a health care provider. 
    • For women planning a pregnancy, it is strongly recommended that you wait at least two months before trying to conceive to ensure that any possible Zika virus infection has cleared your body.
    • For male travellers, Zika virus can persist for an extended period of time in the semen of infected males, therefore
      • It is strongly recommended that, if you have a pregnant partner, you should use condoms for the duration of the pregnancy.
      • It is strongly recommended that you and your partner wait to conceive for six months by using a condom.
      • It is recommended that you should consider using condoms withany partner for six months.
  • Travellers should protect themselves from mosquito bitesExternal link at all times, as the Zika virus is transmitted by a mosquito that can bite in daylight and evening hours. These mosquitoes generally do not live or transmit disease at elevations above 2,000 meters. A list of how to prevent insect bitesExternal link is available on the Government of Canada’s website.
  • Most people who have Zika virus illness will have mild symptoms that resolve with simple supportive care. If you are pregnant, or you have underlying medical conditions, or you develop more serious symptoms that could be consistent with Zika virus infection, you should see a health care provider and tell them where you have been travelling or living.

In order to keep updated, please refer to the PHAC list of countries with reported cases of locally acquired Zika (this list gets updated on a regular basis):
http://www.healthycanadians.gc.ca/diseases-conditions-maladies-affections/disease-maladie/zika-virus/risks-countries-pays-risques-eng.php

Extracted from “Public Health Agency of Canada”
http://www.phac-aspc.gc.ca/tmp-pmv/notices-avis/notices-avis-eng.php?id=152

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measles disease

Measles: Global Update

Travel Health Notice

MeaslesExternal link is a highly contagious viral disease. It is one of the leading causes of death in young children worldwide. Measles cases occur around the world.

Within the last 10 years, the number of measles cases reported globally has decreased significantly; however, there have been a number of large outbreaks, mostly in Africa and Europe. The Americas, including Canada and the United States, have experienced outbreaks of measles, when the virus has been imported from other regions.

Travellers who are not immune to measles (those who have not been fully vaccinated or have not been previously infected with the disease) have an increased risk of infection. For example, travel through international airports, including those in Canada, may increase your chance of exposure to the disease.

The Public Health Agency of Canada reminds travellers to make sure their measles vaccination is up-to-date.

Where is measles a concern?

Measles remains a common disease worldwide. In many regions of the world including Africa, Asia, Europe and Oceania, measles is present (endemic) and large outbreaks can occur. Travellers who are not immune are at risk. A map of reported measles cases worldwideExternal link is available on the World Health Organization (WHO) website.

  • China: In 2015, more than 41,000 cases of measles were confirmed in China. Cases of measles have been reported in travellers who arrived in Canada from China.
  • India: In 2015, over 67,000 cases of measles were confirmed in India.  Since 2010, 11 cases of measles have been reported in travellers who arrived in Canada from India, with the most recent case reported in March 2016.
  • Pakistan: Measles is endemic in Pakistan, and there have been reported cases of measles among travellers who arrived in Canada from Pakistan.  In 2016, all reported importations have been young children, most of whom were too young to be immunized.

In Canada, measles has been eliminated since 1998. However, Canada will continue to see measles cases related to travel to countries where measles is endemic or there are large outbreaks.

Recommendations

Consult a health care provider or visit a travel health clinic preferably six weeks before you travel.

  1. Get vaccinated
    Canadians are reminded to keep all vaccinations up-to-date. See therecommended routine vaccine schedule for further information.

    Travellers should be up-to-date on measles immunization regardless of their travel destination.

  • Infants (6 months to 12 months):
    • During outbreaks or for travel to regions where measles is a concern, the vaccine may be given as early as six months of age. Under these circumstances, the routine two dose series must be then restarted on or after the first birthday, for a total of three doses.
  • Children/adolescents (12 months to 17 years of age):
    • Two doses of a measles-containing vaccine are recommended for children.
    • The first dose should be given at 12-15 months of age and the second dose should be given at 18 months of age or any time thereafter, typically before school entry.
  • Adults (18 years of age and older):
    • Adults born in or after 1970 should make sure that they have received two doses of measles-containing vaccine.
    • Travellers born before 1970 should receive one dose of measles containing vaccine if they do not have one of the following:
      • documented evidence of receiving measles-containing vaccine on or after their first birthday;
      • laboratory evidence of immunity (e.g. through blood testing); or
      • a history of laboratory confirmed measles disease.
  1. Wash your hands frequently
    • Wash your hands with soap under warm running water for at least 20 seconds, as often as possible.
    • Use alcohol-based hand sanitizer if soap and water are not available. It’s a good idea to always keep some with you when you travel.
  2. Practise proper cough and sneeze etiquette
    • Cover your mouth and nose with your arm to reduce the spread of germs.
    • If you use a tissue, dispose of it as soon as possible and wash your hands afterwards.
  3. Monitor your health
    • If you develop symptoms similar to measles when travelling or afteryour return to Canada, you should see a health care provider:
      • Describe your symptoms to the health care provider before your appointment, so that he/she can arrange to see you without exposing others to measles. It is best to avoid close contact with other people for four days after the rash first appears to reduce the spread to others who may not be vaccinated.
      • Remember to tell the health care provider which countries you have travelled to.
    • If you are still ill upon arrival into Canada, please tell the flight attendant before you land or the border services officer as you exit the flight.

Extracted from “Public Health Agency of Canada”
http://www.phac-aspc.gc.ca/tmp-pmv/notices-avis/notices-avis-eng.php?id=98

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yellow fever disease

Yellow fever in Angola

Travel Health Notice

The Ministry of Health of Angola is reporting an ongoing outbreak of yellow fever, primarily in Luanda province.  The outbreak started in December 2015 in the municipality of Viana and has since spread to other provinces.

Yellow feverExternal link is a serious and occasionally fatal disease. It is caused by a virus which is spread to humans by infected mosquitoes.  Symptoms can include fever, chills, headache, muscle pain (mostly back pain), yellowing of the skin and eyes (jaundice), loss of appetite, nausea and vomiting.

Yellow fever transmission occurs in Africa and South America.  The government of Angola requires that travellers over 9 months of age show proof of yellow fever vaccination to enter the country.

The Public Health Agency of Canada recommends that travellers get vaccinated against yellow fever and protect themselves from mosquito bites if travelling to Angola.

Recommendations

Consult a health care provider or visit a travel health clinic, preferably six weeks before you travel.

  • Get vaccinated:
  • It is required that you get the yellow fever vaccine before you travel to Angola as this country:
  1. requires proof of yellow fever vaccination to enter (on anInternational Certificate of Vaccination or Prophylaxis)
  2. has a risk of yellow fever transmission
  • Protect yourself from mosquito bitesExternal link at all times, as the yellow fever virus is transmitted by a mosquito that can bite in daylight and evening hours. This includes the use of insect repellant and protective clothing.
  • If you develop symptoms similar to yellow fever when you are travelling or after you return, see a health care provider and tell them where you have been travelling or living.

Extracted from “Public Health Agency of Canada”
http://www.phac-aspc.gc.ca/tmp-pmv/notices-avis/notices-avis-eng.php?id=159

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