MICHAEL LONG, Director CAROLINE CALDERONE BAISLEY DIVISION OF ENVIRONMENTAL SERVICES DIRECTOR OF HEALTH DOUGLAS SERAFIN, Laboratory Director DEBORAH TRAVERS, Director DIVISION OF FAMILY HEALTH ROBIN CLARK-SMITH, Director OFFICE OF SPECIAL CLINICAL SERVICES

DEPARTMENT OF HEALTH Date: 3/7/16

[Some content within is subject to change as more information DISEASE becomes available] Questions and Answers

What is Zika Virus and where did it come from?

The Zika virus is a -borne flavivirus transmitted primarily by the aegypti mosquito (primary vector). The virus was first isolated from a rhesus monkey in Uganda in 1947 and found in the Aedes Africanus mosquito in 1948. The virus was limited to Africa and Asia, infrequently causing human illness (in 1954, isolated in humans from Nigeria). Currently, these areas are endemic with Zika virus as it continues to circulate. In 2007 an outbreak of the Zika virus was found on Yap Island in the South Pacific and in 2013 spread to the French Polynesia Pacific Islands of New Caledonia, Cook Islands and Eastern Islands. In May 2015, the World Health Organization (WHO) reported the Zika virus in Brazil, the first local transmission in the region of the Americas. In December 2015, the first locally acquired (index) case of Zika virus disease in a jurisdiction of the U.S. was reported in a patient from Puerto Rico. As of February 18, 2016, a total of 32 countries and territories worldwide have active transmission of Zika virus. According to the Centers for Disease Control and Prevention (CDC), the Zika virus may infect up to 4 million people by the end of 2016.

Is there protection against acquiring the Zika Virus?

There is no available vaccine to prevent Zika virus infection and no specific treatment for Zika virus related illness except for supportive care. Antiviral treatment is not currently available for Zika virus disease. The best prevention at this time is avoiding mosquito bites in countries/territories where the Zika virus and other related viruses (, virus) are in the mosquito population. The following steps should be taken:

 Wear long-sleeved shirts and long pants.  Use window/door screens to prevent mosquitoes from entering inside or stay in places with air conditioning.

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 Use mosquito netting when sleeping outdoors or when not able to protect yourself from mosquito bites.

 Use Environmental Protection Agency (EPA) registered repellants. When used as directed, EPA registered insect repellants are proven safe and effective, even for pregnant and breast feeding women. Always follow label instructions.

 DEET  Picaridin (known as Bayrepel or KBR 3023)  P-menthane-diol (PMD) or oil from lemon eucalyptus (OLE) [should not be used on children <3 years]. PMD (Products Containing OLE include Repel and OFF Botanicals)

 IR3535  Reapply insect repellants as directed  Never spray insect repellant on the skin under clothing  When using sunscreen, always apply sunscreen first before applying insect repellant

Children or Babies:

 Do not use insect repellant on babies younger than 2 months old  Cover the legs and arms of children and babies with clothing  Cover crib, stroller and baby carrier with mosquito netting  Do not apply insect repellant to a child’s hands, eyes, mouth or cuts or irritated skin  As an adult, spray insect repellant onto your hands and then apply to a child

Clothing and Gear:

 Follow insect repellant product instructions very carefully when treating your clothing/gear

 Use permethirin to treat clothing and gear only  Treated clothing will remain protective after multiple washings – see insect repellant product information

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What should I do if I have traveled to countries or territories with Zika virus transmission and develop symptoms during travel or when I arrive back in the U.S.?

If you have traveled to a country or territory with Zika virus transmission and have been diagnosed with Zika virus disease or have Zika virus symptoms, protect others from getting sick by avoiding mosquito bites during the first week of illness. Zika virus usually remains in the blood of an infected person for about one week, but it can be longer for some people. Sexual transmission of the Zika virus is possible and might be more common than previously reported. Sexual transmission of the virus is of particular concern during pregnancy. Pregnant women should discuss their male partner’s potential exposure to mosquitoes and history of Zika-like illness with their health care provider. Men who have traveled to areas with Zika virus transmission and who had virus symptoms during and at the end of travel and who have a pregnant partner should abstain from sexual activity or consistently and correctly use condoms during sexual intercourse (vaginal, anal or fellatio) for the duration of the pregnancy. Men without a pregnant sex partner who are ill with Zika virus-like symptoms and who have traveled to areas with Zika virus transmission should discuss with their sex partner the options of abstaining from sexual activity or using condoms consistently and correctly during sex. Couples considering these options should take into consideration the fact that most infections are asymptomatic. These recommendations are based upon previous and recent confirmed and probable cases of sexual transmission of the virus from symptomatic men to female partners. Sexual transmission of the Zika virus from infected women to their sex partners has not been documented nor has transmission from persons who are asymptomatically infected.

CDC guidelines are subject to change as more information becomes.

What are the symptoms and possible complications associated with Zika virus disease?

Most Zika virus infections exhibit no symptoms (estimated in 80% of cases) and when illness does occur, it is usually mild and can go unnoticed. The incubation period (the time from exposure to symptoms) is likely 3 days to 2 weeks. Deaths from Zika virus infection appear to be rare in persons of all ages. Symptoms usually appear 2 to 7 days after a bite from an infected mosquito, with low grade fever (less then 38.5oC), rash, muscle pain, joint pain with possible swelling (usually joints of hands and feet), headache and conjunctivitis (red eyes). It is estimated that one in four people with Zika virus infection develops symptoms. Guillain-

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Barré syndrome (a rare disorder where a person’s own immune system damages the nerve cells, causing muscle weakness and sometimes paralysis) has been reported following Zika virus infection. Although a causal link has not been established between the Zika virus and the Guillain-Barré syndrome, evidence suggests a relationship. During the outbreak in Brazil, an increase in birth defects (microcephaly [small heads], a serious birth defect of the brain and other abnormalities) among infants born to women infected with the Zika virus during pregnancy was observed in a number of cases. These observed findings were believed to be associated with the virus and laboratory evidence supported this potential association. A recent report noting some fetal adverse outcomes (2 early pregnancy losses and 1 live birth with severe microcephaly) in 9 U.S. pregnant travelers with Zika virus infection suggests that there is mounting evidence linking maternal Zika virus infection with congenital microcephaly, miscarriages and other adverse reproductive health outcomes.

What kind of mosquitoes carries the Zika virus and other related viruses?

The is the primary mosquito vector that carries the Zika virus. This mosquito can also spread dengue and chikungunya viruses. Aedes aegypti are sneaky, aggressive daytime biters, but can bite at night. They have typically been restricted to tropical and subtropical regions of the world and are not routinely found beyond Alabama, Mississippi, Georgia and South Carolina in the U.S. The Aedes aegypti mosquito is not found in Connecticut; however, a related mosquito species Aedes albopictus (Asian Tiger Mosquito) is capable of transmitting the virus, as well as dengue and chikungunya viruses. The degree to which transmission from this species may occur over time is not known. Both mosquitoes can breed in any container (large or small) that collects water. Aedes albopictus has been identified in some areas of southwestern Connecticut in low numbers. At this time, according to the State of Connecticut, the Aedes albopictus mosquito is not likely to present a risk of Zika virus infection to people in Connecticut. The Connecticut Agricultural Experiment Station (CAES) in New Haven conducts routine yearly mosquito trapping and testing in the state for several mosquito-borne viruses such as (WNV) from June to October. This year the mosquito surveillance monitoring program will look for the Zika virus.

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Who is at risk of getting the Zika virus and is testing available?

Pregnant women who reside in or who have traveled to countries or territories where there is Zika virus transmission are at high risk if exposed. Pregnant women with clinical illness consistent with Zika virus disease (need to include two or more of the following signs and symptoms: acute onset of fever, maculopopulas rash, arthralgia or conjunctivitis) during or within two weeks of travel should be evaluated by their health care provider for testing. Because exposure to other related circulating viruses (dengue and chikungunya) could present overlapping symptoms, testing for the presence of these viruses in pregnant women may be recommended. Asymptomatic pregnant women may be offered testing within a specific timeframe (2 to 12 weeks) after returning from countries or territories where there is ongoing Zika virus transmission. These pregnant women should consult with their health care provider about getting tested. Women who are planning to become pregnant and who are returning from countries and territories where there is Zika virus transmission are encouraged to speak with their health care provider.

Sexual transmission of the Zika virus is possible and is of particular concern during pregnancy. Recent reports from the CDC suggest that sexual transmission from men to women may be more common that first thought. Men who reside in or who have traveled to countries or territories where there is Zika virus transmission and who have a pregnant partner, should abstain from sexual activity or consistently and correctly use condoms during sex (vaginal, anal or fellatio) for the duration of the pregnancy. Pregnant and non-pregnant women who have not traveled to areas with Zika virus transmission, but had condomless sex with their male partner who had traveled to an area of ongoing Zika virus transmission and who had symptoms of Zika virus disease during travel or within two weeks of returning, are considered potentially exposed. Women in this category should talk to their health care provider about testing. After infection, Zika virus might persist in semen when it is no longer detectable in blood. The length of time the virus might persist in semen is unknown. As more information becomes available, recommendations will be made by the CDC. Because maternal-infant transmission of Zika virus during delivery is possible, acute Zika virus disease should be suspected in a newborn infant during the first two weeks of life whose mother traveled to or resided in an affected area within two weeks of delivery and who has two or more Zika virus symptoms (fever, rash, conjunctivitis or arthralgia). Acute Zika virus disease should also be suspected in an infant or

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child aged <18 years who traveled to or resided in an affected area within the past two weeks and has two or more Zika virus symptoms (fever, rash, conjunctivitis or arthralgia). Men who reside in or who have traveled to countries/territories where there is Zika virus transmission and who are concerned about sexual transmission of Zika virus, might consider abstaining from sexual activity or consistently and correctly use condoms during sex. Couples considering this personal decision should take several factors into account such as, most infections are asymptomatic and when illness does occur, it is usually mild, lasting several days to a week. Hospitalization is uncommon. The risk for acquiring mosquito vector-borne Zika virus in areas of ongoing Zika virus transmission depends on duration and extent of exposure to infected mosquitoes, along with steps taken to prevent mosquito bites. Sexual transmission of many infections, including those caused by viruses, is reduced by consistent and correct use of a latex condom. When more information becomes available, recommendations to prevent sexual transmission of the Zika virus will be made. Zika virus testing is currently recommended to establish a diagnosis of infection in all exposed persons with signs and symptoms consistent with Zika virus disease. Testing is also being offered to asymptomatic pregnant women who had possible exposure to the Zika virus. Women who were potentially exposed and are planning to become pregnant after traveling to affected areas where there is Zika virus transmission should speak to their health care provider. At this time, exposed asymptomatic men who have traveled to where there is Zika virus transmission for the purpose of assessing risk for sexual transmission of the virus is not recommended.

If I am pregnant or planning to become pregnant and have a scheduled trip to areas where there is Zika virus transmission, should I keep my plans?

The Centers for Disease Control and Protection (CDC) has issued a travel alert advisory to all women who are pregnant and planning to travel to areas where there is Zika virus transmission. The CDC advises that pregnant women postpone their travel plans to these areas. Women who are planning to become pregnant are encouraged to talk to their health care providers about their travel plans. Individuals who plan to travel to countries or territories where there is Zika virus transmission should be vigilant in protecting themselves against mosquito bites.

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How many countries have Zika virus transmission?

At this time the Zika virus is currently in areas of Cape Verde, Caribbean, Central America, Mexico, Pacific Islands and South America.

Is the Emergence of the Zika virus a real problem and possible threat to the U.S.?

Yes, on February 1, 2016, the World Health Organization (WHO) declared the Zika virus outbreak in countries and territories when there is Zika virus transmission a Public Health Emergency of International concern. It is expected that Zika virus transmission will increase in these countries and territories and as a result, the incidence of infection in returning travelers to the U.S. will increase. As of March 2, 2016, there were 153 travel–associated Zika virus disease cases reported in the U.S. The possibility of local transmission of the virus could be carried out by infected persons coming in contact with a vector mosquito. To date there are no locally acquired vector-borne cases in the U.S. Sexual transmission of the Zika virus has become more common than previously reported, so this type of transmission is still a concern and is being closely monitored by the CDC.

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ZIKA VIRUS INFORMATION WEBSITES

CDC Information and Guidelines:

 http://www.cdc.gov/zika; http://www.cdc.gov/zika/disease-qa.html

General information about Zika virus and disease:

 http://ww.cdc.gov/zika

Protection against mosquitoes:

 http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/protection-against-

mosquitoes-ticks-other-

 www.cdc.gov/zika/prevention/index.html

Travel notices related to Zika virus:

 http://wwwnc.cdc.gov/travel/notices

Approximate distribution of Aedes aegypti and Aedes Albopictus mosquitoes in the United States:

 http://www.cdc.gov/chikungunya/resources/vector-control.html

Areas where Zika virus is found:

 http://www.cdc.gov/zika/geo/index.html

Insect Repellent Use and Safety:

 http://www.cdc.gov/westnile/faq/repellent.html

 http://www.epa.gov/insect-repellents/using-insect-repellents-safely-and-effectively

American Academy of Pediatrics:

 http://www.healthychildren.org/english/safety-prevention/at-play/pages/insect-

repellents.aspx

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