16 May 2016

Zika virus – update and advice for travellers including pregnant women and those planning pregnancy

It is recommended that pregnant women planning to travel, postpone non-essential travel to areas with active ZIKV transmission until after pregnancy Zika virus – update and advice for travellers including pregnant women and those planning pregnancy

NEW: Areas considered to have current active ZIKV transmission have changed to those with confirmed, locally acquired, vector borne cases in the last 3 months.

This updates and replaces the news item of 15 April 2016.

Specific areas where current active ZIKV transmission is ongoing are often difficult to determine, and subject to change over time. Information is provided in the ‘other risk’ section of our country information pages, and these will continue to be updated as new information becomes available.

Map: Countries or territories with reported confirmed autochthonous (locally acquired) cases of Zika virus infection in the past 3 months

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Source: ECDC

The map above outlines the countries or territories with reported confirmed locally acquired cases of Zika virus infection in the last three months. The European Centre of Disease Prevention and Control (ECDC) provides updated information on current active ZIKV transmission.

In addition, a map of countries or territories that have reported active ZIKV transmission in the past nine months has been provided by ECDC to assist healthcare professionals advising returned travellers who are pregnant.

ZIKV is a dengue-like virus that is transmitted by Aedes mosquitoes, most commonly Aedes aegypti. The infection often occurs without symptoms but can also cause an illness similar to dengue. For those with symptoms, the disease is usually mild and short-lived. Serious complications and deaths from ZIKV are not common. However, based on a growing body of research, there is scientific consensus that Zika virus is a cause of microcephaly and other congenital anomalies, and Guillain-Barré syndrome [1-5]. These complication continue to be investigated, and from hereon, the congenital anomalies (congenital malformations and other nervous system complications, including microcephaly) associated with Zika virus infection will be referred to as Congenital Zika Syndrome (CZS).

In Brazil, as of 7 May 2016,  7,438 suspected cases of fetal/neonatal microcephaly reported since 22 October 2015, 1,326 have been confirmed as microcephaly and/or other abnormalities of the central nervous system, suggestive of congenital Zika virus infection. The majority of confirmed cases of microcephaly occurred in municipalities in the North Eastern region. A total of 262 deaths have been reported (56 confirmed as due to abnormalities of the central nervous system (CNS), including microcephaly, suggestive of CZS) [6]. The latest situation report on microcephaly in Brazil is available from the Ministry of Health, Brazil.

Other countries, with recent reports of ZIKV activity, have also reported cases of fetal microcephaly and/or abnormalities of the CNS, detected during pregnancy or in new-borns and suggestive of CZS [5, 7, 8].

There is now scientific consensus that Zika virus is a cause of Guillain-Barré syndrome. A potential association of ZIKV with Guillain–Barré syndrome (GBS) was first reported in 2014, during an outbreak in French Polynesia [9]. Since the first locally acquired cases of ZIKV were confirmed in north-east Brazil in May 2015, thirteen countries or territories globally have reported increased incidence of GBS and/or laboratory confirmed ZIKV infection in GBS cases [1, 5, 8, 10].

Advice for travellers

A map of countries and territories (or areas) that are currently reporting active ZIKV transmission (i.e. local ZIKV infections have been reported by health authorities) within the previous 3 months is shown above.

In addition, our Country Information pages ‘Other Risk’ section shows countries with areas of current active ZIKV transmission, and countries that have experienced active ZIKV transmission in the last 9 months (which will be relevant if you have travelled to areas affected and became pregnant during that time or in the months following – please see advice section below). 

Aedes mosquitoes transmit ZIKV (as well as diseases such as chikungunya, dengue and yellow fever). Aedes mosquitoes bite predominantly in the day, particularly during mid-morning and late afternoon to dusk. This type of mosquito is unlikely to be found at altitudes over 2,000m.

There is currently no vaccine available to prevent ZIKV.

If you are travelling to regions where these diseases occur you should ideally seek travel health advice from your GP, practice nurse or a travel clinic at least 4-6 weeks before you travel. Even if time is short it is still not too late to get advice. This is particularly relevant if you are pregnant, planning to become pregnant, suffer from a severe, chronic medical condition, or have a medical condition that weakens your immune system.

You should take insect bite avoidance measures during daytime and night time hours, to reduce the risk of infection with ZIKV and other mosquito borne diseases. A good repellent containing N, N-diethylmetatoluamide (DEET) should be used on exposed skin, together with light cover-up clothing. If sunscreen is needed, repellent should be applied after sunscreen. Sunscreen should be 30 SPF or above to compensate for DEET- induced reduction in SPF. Any additional concerns should be discussed with your healthcare provider.

If you are a UK national who lives in an area with active ZIKV transmission, and you have concerns, you should seek advice from your local healthcare provider who will be able to advise you based on your individual circumstances.

A. Pregnant women and their male partners who are planning to travel

There is now scientific consensus that ZIKV infection during pregnancy is a cause of some birth defects such as abnormalities of the central nervous system, including microcephaly.

If you are pregnant, you should discuss your travel plans with your healthcare provider to assess your risk of infection with ZIKV and receive advice on insect bite avoidance measures. See information on factors that health professionals should consider when assessing the risk of infection with ZIKV.

  • It is recommended that if you are pregnant and planning to travel, you should postpone non-essential travel to areas with current active ZIKV transmission until after pregnancy.
  • In the event that travel to an area with active ZIKV transmission cannot be postponed, you should make sure you are fully aware of the risks ZIKV may present.
  • In addition, you should be scrupulous with mosquito bite avoidance measures both during daytime and night time hours (but especially during mid-morning and late afternoon to dusk, when the mosquito is most active). Public Health England has produced an information leaflet: mosquito bite avoidance for travellers.
  • If your female partner is pregnant, condom use is advised during vaginal, anal and oral sex to reduce the risk of transmission during travel and for the duration of the pregnancy even if you did not develop symptoms compatible with ZIKV infection.

B. Pregnant women who have travelled

  • If you are pregnant and you have recently travelled in an area reporting active ZIKV transmission in the last 9 months, you should seek advice from your GP or midwife on your return to the UK, even if you have not been unwell. Your GP or midwife will discuss whether you need fetal ultrasound scanning, and, if necessary, referral to the local fetal medicine service.
  • If you are currently experiencing symptoms suggestive of ZIKV infection, your GP will arrange testing as appropriate.

C. Women planning pregnancy or at risk of getting pregnant and their male partners

If you are planning to become pregnant, you should discuss your travel plans with your healthcare provider to assess your risk of infection with ZIKV and, where travel is unavoidable, receive advice on mosquito bite avoidance measures. See information on factors that health professionals should consider when assessing the risk of infection with ZIKV.

  • You should seek advice from your healthcare provider on the potential risks of ZIKV infection in pregnancy. It is recommended that you avoid becoming pregnant while travelling in an area with active ZIKV transmission, and for 28 days after your return home. This allows for a maximum 2-week incubation period (the time between exposure to an infection and the appearance of the first symptoms) and a possible 2-week viraemia (presence of virus in the bloodstream.) Following this, attempts to conceive can resume.
  • In addition, you should be scrupulous with mosquito bite avoidance measures both during daytime and night time hours (but especially during mid-morning and late afternoon to dusk, when the mosquito is most active). Public Health England has produced an Information leaflet: mosquito bite avoidance for travellers.
  • If you are planning pregnancy and you develop symptoms compatible with ZIKV infection on your return to the UK, seek advice from your GP; testing will be arranged as appropriate. It is recommended you avoid becoming pregnant for a further 28 days following recovery.
  • For women with a male partner who has travelled to an area with active ZIKV transmission, effective contraception is advised to prevent pregnancy AND condom use is advised for your partner  during vaginal, anal and oral sex to reduce the risk of transmission during travel and:
    • for 28 days after his return from an active ZIKV transmission area if he has not had any symptoms compatible with ZIKV infection
    • for 6 months following the start of symptoms if a clinical illness compatible with ZIKV infection or laboratory confirmed ZIKV infection was reported.

Following this, attempts to conceive can resume.

This is a precaution and may be revised as more information becomes available.

D. Preventing sexual transmission

Almost all cases of ZIKV are acquired via mosquito bites. A small number of cases of sexual transmission of ZIKV have been reported (male-to-female and male-to-male transmission). In a limited number of cases, the virus has been shown to be present in semen, although it is not yet known how long this can persist. The risk of sexual transmission of ZIKV is thought to be low, but the number of reports is increasing.

ZIKV infection usually causes no symptoms or is a mild illness. Couples who are not at risk of pregnancy (for example those using other forms of contraception) who wish to reduce the risk of transmission may consider using condoms during vaginal, anal and oral sex if the man had clinical illness compatible with ZIKV infection. Condom use should commence at the onset of the illness and continue for 6 months.

This is a precaution and may be revised as more information becomes available. Individuals with further concerns regarding potential sexual transmission of ZIKV and options for contraception should contact their GP for advice.

Advice for health professionals

In addition to the ECDC maps shown above, health professionals can check for the latest ZIKV outbreak information on our Outbreak Surveillance section. Information on countries experiencing current active ZIKV transmission and active transmission in the last 9 months is also available in the ‘Other Risk’ section of our Country Information pages.

A comprehensive risk assessment should be undertaken for any traveller going to areas with active ZIKV transmission. See information on factors that health professionals should consider when assessing the risk of infection with ZIKV.

Health professionals should recommend that:

  • Pregnant travellers postpone non-essential travel to areas with current active ZIKV transmission until after pregnancy. In addition it is recommended that women should avoid becoming pregnant while travelling in an area with current active ZIKV transmission, and for 28 days after leaving an area with active ZIKV transmission.
  • In the event that travel to an area with current active ZIKV transmission cannot be postponed, the pregnant traveller or those planning pregnancy must be informed by the healthcare provider of the risks which ZIKV may present. In addition, the use of scrupulous mosquito bite avoidance measures both during daytime and night time hours (but especially during mid-morning and late afternoon to dusk, when the mosquito is most active) should be emphasised, and an information leaflet provided.
  • Pregnant women who visited an area with active ZIKV transmission while pregnant, or who become pregnant within 28 days of leaving this country, should contact their GP, obstetrician or midwife for further advice, even if they have not been unwell. Further information about when to perform fetal ultrasound scanning, and, if necessary, referral to the local fetal medicine service is available.
  • Travellers should be advised about potential sexual transmission of ZIKV and the risks ZIKV may pose in pregnancy; specific advice on sexual transmission can be found in the ‘Advice for travellers’ section above.

ZIKV should be considered among the differential diagnoses of patients with fever, or other symptoms suggestive of ZIKV infection, returning from countries with active ZIKV transmission. Further information about diagnosis is available from Public Health England.

If a case of ZIKV infection is suspected, samples need to be sent to PHE’s Rare and Imported Pathogens Laboratory (RIPL); this should be done by liaising with the local diagnostic laboratory. In addition to completing any local laboratory request form, a RIPL request form also needs to be completed by the clinician assessing the patient.

Guidance for health professionals on assessing pregnant women with a history of travel to an area with active ZIKV transmission during pregnancy is available from Public Health England [11].

Health professionals should also be vigilant for any increase of neurological and autoimmune syndromes (in adults and children), or congenital malformations/birth defects in new born infants (where the cause is not otherwise evident) in patients with a history of travel to areas where with active ZIKV transmission is known to occur [12, 13].

Resources

  1. World Health Organization, Zika situation report. 14 April 2016. [Accessed 15 April 2016]
  2. Martines RB, Bhatnagar J, Keating MK, et al. Notes from the Field: Evidence of Zika Virus Infection in Brain and Placental Tissues from Two Congenitally Infected Newborns and Two Fetal Losses — Brazil, 2015. MMWR Morb Mortal Wkly Rep 2016;65:1–2. [Accessed 15 April 2016]
  3. D. B. Miranda-Filho, C. Maria Turchi Martelli, R. Arraes de Alencar Ximenes, et al. Initial description of the presumed congenital zika syndrome. American Journal of Public Health: April 2016, Vol. 106, No. 4: 598–600 [Accessed 15 April 2016]
  4. Rasmussen SA, Jamieson DJ, Honein MA, Petersen LR. Zika Virus and Birth Defects – Reviewing the Evidence for Causality. NEJM April 16 [on-line]. [Accessed 15 April 2016]
  5. European Centres for Disease Prevention and Control. Rapid Risk Assessment – Zika virus disease epidemic: potential association with microcephaly and Guillain- Barré. Fifth update 11 April 2016 [Accessed 15 April 2016]
  6. Ministério da Saúde Brazil. Centro de operações de emergências em saúde pública sobre microcefalias. Informe Epidemiológico nº 21 – semana epidemiológica (se) 14/2016 (3/4 A 9/4/2016). Monitoramento dos casos de microcefalias no Brasil [In Portuguese]. [Accessed 15 April 2016]
  7. Pan American Health Organization / World Health Organization. Zika Epidemiological Update, 8 April 2016. Washington, D.C.: PAHO/WHO; 2016 [Accessed 15 April 2016]
  8. World Health Organization. Zika virus microcephaly and Guillan Barré syndrome: Situation Report. 7 April 2016. [Accessed 15 April 2016]
  9. European Centre for Disease Control and Prevention. Zika virus outbreak French Polynesia. 14 February 2014. [Accessed 15 April 2016]
  10. Public Health England. Zika virus and Guillain-Barré syndrome. 9 March 2016 [Accessed 15 April 2016]
  11. Public Health England. Zika virus: interim algorithm for assessing pregnant women with a history of travel during pregnancy to areas with active Zika virus (ZIKV) transmission. 26 April 2016. [Accessed 27 April 2016]
  12. Public Health England. Guidance: Zika virus congenital infection: algorithm and interim guidance for neonatologists and paediatricians. 24 March 2016 [Accessed 15 April 2016]
  13. Royal College of Obstetricians and Gynaecologists: Public Health England briefing on the Zika virus and vector borne diseases for returning travellers [Accessed 15 April 2016]

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