Zika Virus Disease: How to Counsel Your Patient About Prevention

Zika virus disease is a nationally notifiable condition

Healthcare providers should report suspected Zika virus disease cases to their state, local, or territorial health department, who will report to the CDC. The ACOG Committee Opinion (August 2019 | Endorsed by SMFM) has updated recommendations, including guidance on prevention that are aligned with CDC.

• Pregnant women should avoid travel to areas with active outbreaks (see CDC maps in ‘Learn More – Primary Sources’ below)
• “Pregnant women and those planning pregnancy should talk to their health care providers about potential risks before traveling to an area where current or past Zika virus transmission has occurred”
• If a pregnant woman opts to travel to these higher risk areas, counseling should focus on preventing mosquito bites

CLINICAL ACTIONS:

Zika virus can be transmitted via mosquito bite or more infrequently, through sexual (vaginal, anal or oral) contact, with blood transfusion now also reported. When counseling women, especially those of reproductive age, there are key points to review relating to exposure, prevention and fetal transmission:

Prevent exposure to infected mosquitoes (Aedes species) if traveling to areas where Zika virus has been reported

• Mosquitoes lay eggs near standing water – avoid areas with standing water; once a week empty, scrub, turn over, cover or throw out items that hold still water
• Use screens and air conditioning when available – alternative is mosquito bed netting, especially if sleeping outdoors
• Wear long-sleeved shirts and pants and consider permethrin-treated clothing and gear
• Insect repellent (EPA registered) – DEET and permethrin can be used if pregnant and reapplication instructions should be carefully followed
• Protect against mosquitoes during the day and night, including dusk and dawn

Use appropriate barrier contraception if not planning pregnancy or already pregnant

• Barrier contraception includes male and female condoms and dental dams
• Pregnant : If a patient’s sex partner (male or female) either lives or has traveled to an active Zika virus transmission area, the use of barriers or abstention from sex for the duration of the pregnancy is recommended
• Does Not Desire Pregnancy : Determine the best contraceptive method for your patient that will be used correctly and consistently. To prevent transmission, barrier use or abstention is recommended for the following length of time if exposed to Zika virus
  • Men : for at least 3 months after onset of symptoms or exposure (if asymptomatic)
  • Women : for at least 8 weeks after onset of symptoms or exposure (if asymptomatic)
  • If a couple resides in an active Zika virus transmission area: for the time that active mosquito-borne transmission persists

Delay attempting desired pregnancy for the following length of time, if diagnosed or exposed to Zika virus

• Men : for at least 3 months after onset of symptoms or exposure (if asymptomatic)
• Women : for at least 8 weeks after onset of symptoms or exposure (if asymptomatic)
• If a couple lives in a high risk area: Provide counseling regarding risk of microcephaly and other birth defects
  • For couples who desire to conceive, mosquito bite prevention strategies are imperative

SYNOPSIS:

While first reported in Africa decades ago, the initial reported case of Zika virus disease in South America was in 2015.  The CDC maintains world maps (open access) to identify active areas. 20% of those infected will be symptomatic. Incubation period has been reported to be between 3 to 14 days. Zika virus became an international health emergency due to the risk of severe birth defects, in particular microcephaly, through maternal transmission.

KEY POINTS:

• CDC recommends that pregnant women not travel to areas where there have been reports of local transmission (color code red on map)
• CDC keeps an updated map of both international and national active transmission area (See ‘Learn More – Primary Sources’ for CDC maps)
• CDC advises that healthcare providers discuss travel plans in preconception counseling, and both women and men should consider avoiding nonessential travel to active transmission areas
  • CDC states that for areas with current or past transmission (as opposed to known outbreak regions and coded purple)

These countries have a potential risk of Zika, but we do not have accurate information on the current level of risk 

As a result, detection and reporting of new outbreaks may be delayed

• CDC defines ‘exposure’ to Zika virus as either of the following:
  • Travel or residency in an area of active Zika virus transmission
  • Sex without a condom with a partner who has lived or traveled to such an area
• Routine Zika virus testing is not currently recommended for women or men with exposure, but who are asymptomatic
• No transmission via ART has been identified, but is possible in theory
• No cases of transmission via breastfeeding have been reported
  • Currently, opinion suggests benefits of breastfeeding outweigh risks
• The most current public health recommendations can be found on the CDC website, which is continuously updating and revising guidance as new evidence becomes available

Learn More – Primary Sources:

ACOG Zika Toolkit

ACOG Committee Opinion 784: Management of Patients in the Context of Zika Virus

CDC: Zika Travel Information (color coded map) 

CDC: Zika in the US

CDC: Zika Virus For Healthcare Providers

Update: Interim Guidance for Preconception Counseling and Prevention of Sexual Transmission of Zika Virus for Men with Possible Zika Virus Exposure — United States, August 2018

WHO Emergencies Preparedness, Response (July 2019): Information for travellers visiting countries with Zika virus transmission 

WHO Zika epidemiology update (July 2019)