Zika: Assessment and Management

Jessica Isnesso - Nursing Faculty

By Jessica Isnetto, DNP, ARNP-C, FNP
Kaplan University School of Nursing

The Zika virus is becoming an increasing concern for women of childbearing years in the United States. The drastic increase of Zika virus infections and the correlation with neurological deficits such as microcephaly in newborns have led to increasing concern among health care providers caring for women who are or desire to be pregnant. This international public health concern has sparked new assessment and management guidelines for those suspected of being in contact with the Zika virus.

The Problem of Zika

The Zika virus was first isolated in 1947 in a febrile rhesus monkey in Uganda and later identified in the Aedes africanus mosquito in the same region.1 The first three human cases of the Zika virus were not discovered until 1954 in Nigeria.2 Initially the virus was thought to be a minor health issue causing those infected to develop only mild fever, rash, and arthralgia in approximately 20% of patients while the other 80% infected would remain asymptomatic.3 After large outbreaks of Zika were noted in the island of Yap in 2007 and Central and South America in 2015–16, a correlation between infection and neurological issues such as microcephaly in newborns and Guillain-Barré syndrome became evident.4 This led to a subsequent increase in research and to the World Health Organization (WHO) declaring Zika a Public Health Emergency of International Concern with Zika being noted as an accepted cause of a major spike in these neurological abnormalities in affected regions.5

The current Zika virus outbreak was identified in Brazil in 2015.6 This rapidly evolving virus was noted in 59 countries and U.S. territories as of September 2016.7 The virus is usually spread as a result of a bite from an infected mosquito but has also been noted to be spread during unprotected sex from an infected male to a partner.8 The increasing data demonstrate that the virus is largely asymptomatic once infected and displays rapid modes of transmission including mosquito bites, mother to child, sexual intercourse, and blood transfusion.9 These factors, along with the links to microcephaly in infants where the mother was infected, prompted the WHO to take the momentous step to recommend women visiting Zika infected areas to delay childbearing up to six months as well as to recommend women who are pregnant to delay travel to affected locations.10

Clinical Presentation

Part of the major concern regarding the Zika infection is the lack of symptomatology in up to 80% of those infected and the vague mild symptoms comparable to the flu or a mild illness in the remaining portion. The lack of major presenting symptoms makes it difficult for patients and providers to identify Zika as a potential concern. Additionally, the incubation period from the mosquito bite to symptom onset is about three to twelve days; during this time, up to 80% of cases are likely to demonstrate no symptoms.11 When symptoms do occur, they are typically mild, self-limiting, and non-specific such as rash, low-grade fever, arthralgia, fatigue, headache, and conjunctivitis, similar to many other airborne viruses.12 The rash of the Zika virus tends to be the most prominent symptom. Typical presentation is pruritic and maculopapular and begins proximally spreading to the extremities with spontaneous resolution in one to four days.13

The more severe clinical presentation of the Zika virus is in infants born to infected mothers. A significant correlation has been documented in Zika affected regions of cases of infants born with microcephaly. Increased reports of infants born with microcephaly in affected regions as well as increased research and pathological evidence support a link between Zika virus infection during pregnancy and adverse outcomes such as pregnancy loss, microcephaly, and brain and eye abnormalities.14 During a maternal infection with the Zika virus, it is thought that the virus will cause microcephaly by viral destruction of the fetus brain tissue.15 Research is currently underway to determine if infection with the Zika virus during conception poses the same risk if someone is further into pregnancy. There is not yet any evidence to support Zika causing congenital issues in pregnancies conceived after the resolution of maternal infection.16

Diagnosis

Because of the ambiguous symptoms of the virus, clinical evaluation alone is an unreliable form of diagnosis for Zika, particularly in patients living in or traveling to affected areas. All pregnant women in the United States and U.S. territories should be assessed for possible Zika exposure at each prenatal visit.17 Evolution of testing algorithms for the Zika virus is complex and constantly changing. Factors to consider include: symptomatic or asymptomatic, duration since onset of symptoms, and pregnancy status. Testing for the Zika virus includes serum and urine methodology. Full testing algorithms are available on the Centers for Disease Control and Prevention website to determine the proper course of screening given each unique patient scenario.

Management

Unfortunately, management of confirmed Zika virus infection is primarily supportive, including rest, fluids, fever control, and analgesics. No specific treatment or vaccine is available for the Zika virus at this time.18 Guidelines at this time are focused on prevention of initial exposure to the virus, including mosquito bite prevention as well as safe sexual practices. Mosquito bite prevention includes long sleeves and pants, light-colored clothing, insect repellants, and avoiding being outdoors in peak mosquito hours such as early mornings and late afternoons.19 Pregnant women are advised to avoid travel to affected areas as well as to engage in safe sexual practices using condoms or abstinence with men where exposure to Zika is a concern.20 Serial fetal ultrasounds should be considered in pregnant women to monitor fetal growth and anatomy every three to four weeks with positive or inconclusive Zika test results, and infant testing should be performed at birth.21

Education

Because of the extremely limited data and constant emerging research on the Zika virus and its effects on pregnancy, it is essential for health care providers to deliver preconception counseling and education to their patients considering pregnancy and outline prevention measures to those already pregnant. Discussions regarding Zika should include information on symptoms of the virus, ease of transmission, and potential adverse outcomes associated with contracting the virus in pregnancy.22 Patients should be provided education on pregnancy prevention options such as contraception and proper use of condoms when residing in active Zika transmission areas and wishing to prevent or delay conception. Women with confirmed Zika virus diagnoses should be educated to wait at least eight weeks after symptom resolution to try and conceive.23

Conclusion

The Zika virus has been declared a public health emergency because of the ease of transmission, relatively benign and asymptomatic virus, and correlation to major neurological complications in newborns where the mother contracted the virus. A continued response from government agencies, local health officials, health care providers, and researchers remains underway to shed new light onto this growing concern. As this epidemic continues to unfold, it remains crucial to educate the public, particularly women of childbearing age, about the inherent risks of the Zika virus and avoidance of infection.

References

  1. Anna R. Plourde and Evan M. Bloch, “A Literature Review of Zika Virus,” Emerging Infectious Diseases 22 no. 7 (2016): 1185–1192.
  2. Plourde and Bloch, “A Literature Review of Zika Virus.”
  3. Phillipe Boeuf, Heidi E. Drummer, Jack S. Richards, Michelle J. L. Scoullar, and James G. Beeson, “The global threat of Zika virus to pregnancy: epidemiology, clinical perspectives, mechanisms, and impact,” BMC Medicine 14 no. 112 (2016).
  4. Phillipe Boeuf et al., “Global threat of Zika virus.”
  5. Phillipe Boeuf et al., “Global threat of Zika virus.”
  6. Emily E. Petersen, Kara N. D. Polen, Dana Meaney-Delman, Sascha R. Ellington, Titilope Oduyebo, Amanda Cohn, Alexandra M. Oster, et al., “Update: Interim Guidance for Health Care Providers Caring for Women of Reproductive Age with Possible Zika Virus Exposure – United States, 2016,” Morbidity and Mortality Weekly Report 65 no. 12 (2016): 315–322.
  7. Emily E. Petersen, Dana Meaney-Delman, Robyn Neblett-Fanfair, Fiona Havers, Titilope Oduyebo, Susan L. Hills, Ingrid B. Rabe, et al., “Update: Interim Guidance for Preconception Counseling and Prevention of Sexual Transmission of Zika Virus for Persons with Possible Zika Virus Exposure – United States, September 2016,” Morbidity and Mortality Weekly Report 65 no. 39 (2016): 1077–1081.
  8. Emily E. Petersen et al., “Interim Guidance for Health Care Providers.”
  9. “Zika Virus: Transmission,” Centers for Disease Control and Prevention, accessed September 28, 2016, http://www.cdc.gov/zika/transmission/index.html.
  10. “Information for travelers visiting Zika affected countries,” World Health Organization, accessed September 28, 2016, http://www.who.int/csr/disease/zika/information-for-travelers/en/.
  11. Plourde and Bloch, “A Literature Review of Zika Virus.”
  12. Plourde and Bloch, “A Literature Review of Zika Virus.”
  13. Plourde and Bloch, “A Literature Review of Zika Virus.”
  14. Emily E. Petersen et al., “Interim Guidance for Health Care Providers.”
  15. Emily E. Petersen et al., “Interim Guidance for Health Care Providers.”
  16. Emily E. Petersen et al., “Interim Guidance for Health Care Providers.”
  17. Emily E. Petersen et al., “Interim Guidance for Preconception Counseling.”
  18. Plourde and Bloch, “A Literature Review of Zika Virus.”
  19. Plourde and Bloch, “A Literature Review of Zika Virus.”
  20. Plourde and Bloch, “A Literature Review of Zika Virus.”
  21. Plourde and Bloch, “A Literature Review of Zika Virus.”
  22. Emily E. Petersen et al., “Interim Guidance for Health Care Providers.”
  23. Emily E. Petersen et al., “Interim Guidance for Health Care Providers.”

 



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