Utah Zika Case Points to Likely New Transmission Route

CDC Updates Interim Guidance, Expands Travel Advisory

October 05, 2016 03:45 pm News Staff

In a new report involving the nation's first reported Zika-related fatality, as well as a subsequent case in a relative of the deceased patient, researchers suggest that the virus may be transmitted through tears or perspiration.

[Elderly man being cared for in hospital bed]

Researchers at the University of Utah School of Medicine and the university's nonprofit enterprise ARUP Laboratories suggest that Zika virus may be transmitted through tears or perspiration, as appears to have been the case in a recent report of transmission between a severely ill hospitalized man and his son.

In other recent developments, the CDC has updated its interim guidance on preventing sexual transmission of the virus, along with its interim response plan. In addition, the agency has issued a new travel advisory recommending that pregnant women avoid visiting certain areas of Southeast Asia.

Possible Zika Transmission via Tears or Sweat

In correspondence published online Sept. 28 in the New England Journal of Medicine,(www.nejm.org) researchers at the University of Utah School of Medicine and the university's nonprofit enterprise ARUP Laboratories, both in Salt Lake City, explored a case of Zika virus transmission that occurred in the state last June that was linked to the first recorded Zika-related death in the United States.

The letter explained that the index case -- a 73-year-old man carrying a viral load more than 100,000 times higher than that typically seen in blood samples from infected patients -- contracted Zika while visiting an area of Mexico where active transmission of the virus was occurring.

Story highlights
  • A recent report suggested that a Zika virus case recently reported in Utah likely was transmitted through tears or perspiration.
  • The CDC has released updated interim guidance for preconception counseling to prevent sexual transmission of Zika, as well as an updated interim response plan.
  • The agency also has expanded its travel advisory for pregnant women to recommend that they avoid visiting certain countries in Southeast Asia where active transmission is occurring.

After returning from his trip, he reported having abdominal pain, pharyngitis and fever, which was followed by conjunctivitis, nonbloody diarrhea and myalgias. By the time he was admitted to the hospital eight days after returning home, he had developed hypotension and dyspnea and was found to have tachypnea and tachycardia on admission.

The physical examination found marked erythematous conjunctivitis with profuse tearing, and lab testing revealed metabolic acidosis, an elevated venous lactate level, renal insufficiency, mild hypoglycemia, elevated aminotransferase levels, leukocytosis, anemia and marked thrombocytopenia. A tourniquet test for dengue virus was negative.

The patient's condition continued to deteriorate, and he went into septic shock, with progressive respiratory and renal failure, metabolic acidosis, and hepatitis. He died four days after admission shortly after care was withdrawn.

Testing for dengue virus on polymerase chain reaction (PCR) assay was negative, although findings on serologic analysis for dengue were consistent with remote infection. Serum testing for Zika virus on real-time PCR assay was positive.

The patient's 38-year-old son had visited his father in the hospital frequently and helped move his father without using gloves and also wiped tears from his father's eyes during these visits. Five days after his father's death, the previously healthy son reported conjunctivitis, fever, myalgia and a facial maculopapular rash. The rash spread but resolved after seven days. At that time, urinalysis was positive for Zika virus but serum was negative on PCR assay. Serum immunoglobulin M antibody to Zika virus was positive.

Congress Approves Zika Funding

On Sept. 28, Congress passed a stopgap spending bill to fund the government through Dec. 9, which included $1.1 billion allocated to fight Zika virus in the United States. This funding will be used to support efforts already underway, such as helping Florida and Puerto Rico spray against Aedes aegypti mosquito populations, distributing Zika test kits to additional states and completing the development of critical Zika virus vaccines.

The letter's authors said it was likely the son acquired the infection from his father because the son had not recently traveled to an area where Zika was active and hadn't had sex with a partner who had traveled to such an area. Furthermore, Aedes mosquitos haven't been detected in Salt Lake City, so infection from a mosquito bite seemed unlikely.

"Given the very high level of viremia in Patient 1, infectious levels of virus may have been present in sweat or tears, both of which Patient 2 contacted without gloves," the correspondence said. "… In addition, the second case occurred seven to 10 days after contact with the index patient in the hospital, which implicates direct contact during hospitalization."

"This rare case is helping us to understand the full spectrum of the disease and the precautions we may need to take in order to avoid passing the virus from one person to another in specific situations," said lead author Sankar Swaminathan, M.D., chief of infectious disease and professor of internal medicine at the medical school, in a news release.(healthcare.utah.edu)

Updated Interim Guidance for Preconception Counseling

In a Sept. 30 Morbidity and Mortality Weekly Report (MMWR),(www.cdc.gov) the CDC offered updated interim guidance for preconception counseling to prevent sexual transmission of Zika virus.

The CDC has combined its interim guidance for patients with possible Zika virus exposure who are planning to conceive with its interim guidance to prevent transmission of Zika virus through sexual contact. The agency defines Zika virus exposure as travel to or residence in an area of active Zika virus transmission or sex without a condom with a partner who traveled to or lived in such an area.

Latest Reported Zika Virus Cases

The Florida Department of Health reported(www.floridahealth.gov) six new nontravel-related cases as of Oct. 4, bringing the total number of nontravel-related cases in the state to 139.

With Florida currently accounting for all of the United States' nontravel-related cases, the CDC reported(www.cdc.gov) that as of Sept. 28, the country has raised its total reported Zika virus case numbers to 3,625 stateside and 22,069 for U.S. territories.

"Based on new, though limited data, the CDC now recommends that all men with possible Zika virus exposure who are considering attempting conception with their partner, regardless of symptom status, wait to conceive until at least six months after symptom onset (if symptomatic) or last possible Zika virus exposure (if asymptomatic)," said the MMWR report.

The agency's recommendations for women who are planning to conceive remain unchanged: Women with possible Zika virus exposure should wait to conceive until at least eight weeks after symptom onset (if symptomatic) or last possible Zika virus exposure (if asymptomatic).

The CDC also said couples with possible Zika virus exposure who aren't pregnant and don't plan to become pregnant but who want to minimize their risk for sexual transmission of Zika virus should consistently use condoms or abstain from sex for the same periods broken down by gender above.

The agency concluded that women of reproductive age who have had or anticipate future Zika virus exposure but who don't want to become pregnant should use the most effective contraceptive method available that can be used correctly and consistently.

Updated Interim Response Plan

The CDC also updated its interim response plan for Zika;(www.cdc.gov) this version replaces the iteration that was posted July 31.

Updates to the plan include

  • revised guidance to ensure blood safety and availability that reflect FDA recommendations issued on Aug. 26,
  • revised guidance on determining geographic areas for intervention and issuing travel guidance in the setting of local transmission, and
  • updated pregnancy and birth defects objectives.

New Travel Advisory for Southeast Asia

Finally, the CDC said in a recent travel advisory that pregnant women should put off travel to certain areas of Southeast Asia where Zika virus has been reported.

Although Zika has been present in this region for years, and many local residents are likely to be immune, this isn't the case for U.S. travelers. Reports of visitors to Southeast Asia acquiring Zika virus infections are on the rise, say CDC officials, and the agency has expanded the list of countries to which nonessential travel should be avoided.

The eleven countries listed in the latest advisory are Brunei, Burma (Myanmar), Cambodia, Indonesia, Laos, Malaysia, Maldives, Philippines, Thailand, Timor-Leste (East Timor) and Vietnam.

Related AAFP News Coverage
AAFP to Host New Zika Virus Webinar on Sept. 16
Live Event Will Be Archived for Later Viewing


As Zika Spreads, Evidence of Link to Birth Defects Grows

AAFP, CDC Field New Tools to Augment Response to Zika Threat
HHS Secretary Warns of Dwindling Funds to Combat the Virus


More From AAFP
Zika Virus Outbreak