Dana Thomas

Local Transmission of Zika Virus — Puerto Rico, November 23, 2015–January 28, 2016

Zika virus, a mosquito-borne flavivirus, spread to the Region of the Americas (Americas) in mid-2015, and appears to be related to congenital microcephaly and Guillain-Barré syndrome (1,2). On February 1, 2016, the World Health Organization (WHO) declared the occurrence of microcephaly cases in association with Zika virus infection to be a Public Health Emergency of International Concern.* On December 31, 2015, Puerto Rico Department of Health (PRDH) reported the first locally acquired (index) case of Zika virus disease in a jurisdiction of the United States in a patient from southeastern Puerto Rico. During November 23, 2015-January 28, 2016, passive and enhanced surveillance for Zika virus disease identified 30 laboratory-confirmed cases. Most (93%) patients resided in eastern Puerto Rico or the San Juan metropolitan area. The most frequently reported signs and symptoms were rash (77%), myalgia (77%), arthralgia (73%), and fever (73%). Three (10%) patients were hospitalized. One case occurred in a patient hospitalized for Guillain-Barré syndrome, and one occurred in a pregnant woman. Because the most common mosquito vector of Zika virus, Aedes aegypti, is present throughout Puerto Rico, Zika virus is expected to continue to spread across the island. The public health response in Puerto Rico is being coordinated by PRDH with assistance from CDC. Clinicians in Puerto Rico should report all cases of microcephaly, Guillain-Barré syndrome, and suspected Zika virus disease to PRDH. Other adverse reproductive outcomes, including fetal demise associated with Zika virus infection, should be reported to PRDH. To avoid infection with Zika virus, residents of and visitors to Puerto Rico, particularly pregnant women, should strictly follow steps to avoid mosquito bites, including wearing pants and long-sleeved shirts, using permethrin-treated clothing and gear, using an Environmental Protection Agency (EPA)-registered insect repellent, and ensuring that windows and doors have intact screens.

Update: Ongoing Zika Virus Transmission — Puerto Rico, November 1, 2015–July 7, 2016

Zika virus is a flavivirus transmitted primarily by Aedes aegypti and Aedes albopictus mosquitoes, and infection can be asymptomatic or result in an acute febrile illness with rash (1). Zika virus infection during pregnancy is a cause of microcephaly and other severe birth defects (2). Infection has also been associated with Guillain-Barré syndrome (GBS) (3) and severe thrombocytopenia (4,5). In December 2015, the Puerto Rico Department of Health (PRDH) reported the first locally acquired case of Zika virus infection. This report provides an update to the epidemiology of and public health response to ongoing Zika virus transmission in Puerto Rico (6,7). A confirmed case of Zika virus infection is defined as a positive result for Zika virus testing by reverse transcription-polymerase chain reaction (RT-PCR) for Zika virus in a blood or urine specimen. A presumptive case is defined as a positive result by Zika virus immunoglobulin M (IgM) enzyme-linked immunosorbent assay (MAC-ELISA)* and a negative result by dengue virus IgM ELISA, or a positive test result by Zika IgM MAC-ELISA in a pregnant woman. An unspecified flavivirus case is defined as positive or equivocal results for both Zika and dengue virus by IgM ELISA. During November 1, 2015-July 7, 2016, a total of 23,487 persons were evaluated by PRDH and CDC Dengue Branch for Zika virus infection, including asymptomatic pregnant women and persons with signs or symptoms consistent with Zika virus disease or suspected GBS; 5,582 (24%) confirmed and presumptive Zika virus cases were identified. Persons with Zika virus infection were residents of 77 (99%) of Puerto Ricos 78 municipalities. During 2016, the percentage of positive Zika virus infection cases among symptomatic males and nonpregnant females who were tested increased from 14% in February to 64% in June. Among 9,343 pregnant women tested, 672 had confirmed or presumptive Zika virus infection, including 441 (66%) symptomatic women and 231 (34%) asymptomatic women. One patient died after developing severe thrombocytopenia (4). Evidence of Zika virus infection or recent unspecified flavivirus infection was detected in 21 patients with confirmed GBS. The widespread outbreak and accelerating increase in the number of cases in Puerto Rico warrants intensified vector control and personal protective behaviors to prevent new infections, particularly among pregnant women.

Disaster-related exposures and health effects among US Coast Guard responders to Hurricanes Katrina and Rita: a cross-sectional study

Objective: Disaster responders work among poorly characterized physical and psychological hazards with little understood regarding health consequences of their work. Methods: A survey administered to 2834 US Coast Guard responders to Hurricanes Katrina and Rita provided data on exposures and health effects. Prevalence odds ratios (PORs) evaluated associations between baseline characteristics, missions, exposures, and health effects. Results: Most frequent exposures were animal/insect vector (n = 1309; 46%) and floodwater (n = 817; 29%). Most frequent health effects were sunburn (n = 1119; 39%) and heat stress (n = 810; 30%). Significant positive associations were for mold exposure and sinus infection (POR = 10.39); carbon monoxide and confusion (POR = 6.27); lack of sleep and slips, trips, falls (POR = 3.34) and depression (POR = 3.01); being a Gulf-state responder and depression (POR = 3.22). Conclusions: Increasing protection for disaster responders requires provisions for adequate sleep, personal protective equipment, and access to medical and psychological support.

Guillain-Barré Syndrome and Healthcare Needs during Zika Virus Transmission, Puerto Rico, 2016

To assist with public health preparedness activities, we estimated the number of expected cases of Zika virus in Puerto Rico and associated healthcare needs. Estimated annual incidence is 3.2–5.1 times the baseline, and long-term care needs are predicted to be 3–5 times greater than in years with no Zika virus.

Reemergence of Dengue in Southern Texas, 2013.

Of 53 cases detected, about half were acquired locally.

Sleep deprivation and adverse health effects in United States Coast Guard responders to Hurricanes Katrina and Rita

OBJECTIVE Disaster responders are increasingly called upon to assist in various natural and manmade disasters. A critical safety concern for this population is sleep deprivation; however, there are limited published data regarding sleep deprivation and disaster responder safety. DESIGN We expanded upon a cross-sectional study of 2695 United States Coast Guard personnel who responded to Hurricanes Katrina and Rita. Data were collected via survey on self-reported timing and location of deployment, missions performed, health effects, medical treatment sought, average nightly sleep, and other lifestyle variables. We created a 4-level sleep deprivation metric based on both average nightly reported sleep (d5hours; >5hours) and length of deployment (d2weeks; >2weeks) to examine the association between sustained sleep deprivation and illnesses, injuries, and symptoms using logistic regression to calculate odds ratios (ORs) and 95% confidence intervals. RESULTS The strongest, statistically significant positive ORs for the highest sleep deprivation category compared with the least sleep-deprived category were for mental health and neurologic effects, specifically depression (OR=6.76), difficulty concentrating (OR=8.33), and confusion (OR=11.34), and for dehydration (OR=9.0). Injuries most strongly associated with sleep deprivation were twists, sprains, and strains (OR=6.20). Most health outcomes evaluated had monotonically increasing ORs with increasing sleep deprivation, and P tests for trend were statistically significant. CONCLUSION Agencies deploying disaster responders should understand the risks incurred to their personnel by sustained sleep deprivation. Improved planning of response efforts to disasters can reduce the potential for sleep deprivation and lead to decreased morbidity in disaster responders.

Dengue Among American Missionaries Returning from Jamaica, 2012

Dengue is an acute febrile illness caused by any of four mosquito-transmitted dengue virus (DENV) types. Dengue is endemic in Jamaica, where an epidemic occurred in 2012. An investigation was conducted by multiple agencies for 66 missionaries traveling from nine US states to Jamaica after 1 missionary from the group was confirmed to have dengue. Travelers were offered diagnostic testing, and a survey was administered to assess knowledge, behaviors, and illness. Of 42 survey respondents, 9 (21%) respondents reported an acute febrile illness during or after travel to Jamaica. Of 15 travelers that provided serum specimens, 4 (27%) travelers had detectable anti-DENV immunoglobulin M antibody, and 1 traveler also had DENV-1 detected by reverse transcriptase polymerase chain reaction. Recent or past infection with a DENV was evident in 93% (13 of 14) missionaries with available sera. No behavioral or demographic factors were significantly associated with DENV infection. This investigation shows that even trips of short duration to endemic areas present a risk of acquiring dengue.

Human Rabies - Puerto Rico, 2015.

On December 1, 2015, the Puerto Rico Department of Health (PRDH) was notified by a local hospital of a suspected human rabies case. The previous evening, a Puerto Rican man aged 54 years arrived at the emergency department with fever, difficulty swallowing, hand paresthesia, cough, and chest tightness. The next morning the patient left against medical advice but returned to the emergency department in the afternoon with worsening symptoms. The patients wife reported that he had been bitten by a mongoose during the first week of October, but had not sought care for the bite. While being transferred to the intensive care unit, the patient went into cardiac arrest and died. On December 3, rabies was confirmed from specimens collected during autopsy. PRDH conducted an initial rapid risk assessment, and five family members were started on rabies postexposure prophylaxis (PEP).

Clinical Features of Guillain-Barré Syndrome With vs Without Zika Virus Infection, Puerto Rico, 2016

Importance The pathophysiologic mechanisms of Guillain-Barré syndrome (GBS) associated with Zika virus (ZIKV) infection may be indicated by differences in clinical features. Objective To identify specific clinical features of GBS associated with ZIKV infection. Design, Setting, and Participants During the ZIKV epidemic in Puerto Rico, prospective and retrospective strategies were used to identify patients with GBS who had neurologic illness onset in 2016 and were hospitalized at all 57 nonspecialized hospitals and 2 rehabilitation centers in Puerto Rico. Guillain-Barré syndrome diagnosis was confirmed via medical record review using the Brighton Collaboration criteria. Specimens (serum, urine, cerebrospinal fluid, and saliva) from patients with GBS were tested for evidence of ZIKV infection by real-time reverse transcriptase–polymerase chain reaction; serum and cerebrospinal fluid were also tested by IgM enzyme-linked immunosorbent assay. In this analysis of public health surveillance data, a total of 123 confirmed GBS cases were identified, of which 107 had specimens submitted for testing; there were 71 patients with and 36 patients without evidence of ZIKV infection. Follow-up telephone interviews with patients were conducted 6 months after neurologic illness onset; 60 patients with and 27 patients without evidence of ZIKV infection participated. Main Outcomes and Measures Acute and long-term clinical characteristics of GBS associated with ZIKV infection. Results Of 123 patients with confirmed GBS, the median age was 54 years (age range, 4-88 years), and 68 patients (55.3%) were male. The following clinical features were more frequent among patients with GBS and evidence of ZIKV infection compared with patients with GBS without evidence of ZIKV infection: facial weakness (44 [62.0%] vs 10 [27.8%]; P < .001), dysphagia (38 [53.5%] vs 9 [25.0%]; P = .005), shortness of breath (33 [46.5%] vs 9 [25.0%]; P = .03), facial paresthesia (13 [18.3%] vs 1 [2.8%]; P = .03), elevated levels of protein in cerebrospinal fluid (49 [94.2%] vs 23 [71.9%]; P = .008), admission to the intensive care unit (47 [66.2%] vs 16 [44.4%]; P = .03), and required mechanical ventilation (22 [31.0%] vs 4 [11.1%]; P = .02). Six months after neurologic illness onset, patients with GBS and evidence of ZIKV infection more frequently reported having excessive or inadequate tearing (30 [53.6%] vs 6 [26.1%]; P = .03), difficulty drinking from a cup (10 [17.9%] vs 0; P = .03), and self-reported substantial pain (15 [27.3%] vs 1 [4.3%]; P = .03). Conclusions and Relevance In this study, GBS associated with ZIKV infection was found to have higher morbidity during the acute phase and more frequent cranial neuropathy during acute neuropathy and 6 months afterward. Results indicate GBS pathophysiologic mechanisms that may be more common after ZIKV infection.

Notes from the Field: Use of Asynchronous Video Directly Observed Therapy for Treatment of Tuberculosis and Latent Tuberculosis Infection in a Long-Term–Care Facility ― Puerto Rico, 2016–2017

To treat a cluster of tuberculosis (TB) transmission cases in a long-term care facility for cognitively impaired adults located in Puerto Rico (facility A), the Puerto Rico TB Control Program used a novel video directly observed therapy (VDOT) application. In 2016, active TB disease was diagnosed in 11 residents and latent TB infection (LTBI) was diagnosed in six residents of facility A. Asynchronous VDOT was used to monitor treatment for these 17 residents. One of the patients with active TB disease had received a diagnosis of LTBI during an investigation at facility A during 2011–2012. During 2010–2012, seven residents of facility A received a diagnosis of active TB disease; four of these diagnoses were culture-confirmed, with isolates that had the same rare genotype (1). Drug susceptibility testing indicated sensitivity to the standard first-line regimen of rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE). Three of the seven TB patients died before starting treatment; the other four were prescribed the RIPE regimen under the supervision of personnel from facility A. Two of the four patients who reportedly completed RIPE treatment in 2012 died in 2016 from unrecognized TB-related conditions; both patients were roommates of the 2016 index case patient. For these two patients, evidence of TB discovered during a postmortem medical record review included ineffective antibiotic treatments for putative community-acquired pneumonia and bronchitis and signs of wasting, which were corroborated by interviews with staff members and treating physician. No patients at facility A tested positive for human immunodeficiency virus infection in 2012 or 2016. The contact investigation performed in 2011–2012 identified LTBI in 26 residents and seven nonresidents. All contacts with LTBI were reported by facility staff members as having completed treatment with 4 months of daily rifampin (4R), one of a few standard LTBI regimens, in 2012. On June 20, 2016, a resident of facility A, who was a contact from the 2011–2012 investigation and whose facility records indicated prior treatment for LTBI with 4R, was identified as having advanced cavitary TB disease; the genotype and drug susceptibility testing of this patient’s isolate matched that of the original cases. This resident began treatment with a 6-month course of RIPE; ethambutol was discontinued after drug sensitivities were confirmed. Among 38 residents and 15 staff members, 10 additional cases of active TB disease were diagnosed among residents; these patients were prescribed rifampin, isoniazid, and pyrazinamide (without ethambutol). Six other residents with diagnosed LTBI were prescribed 4R treatment. Because of staffing shortages, Puerto Rico Department of Health (PRDH) TB field personnel were not available to administer daily directly observed therapy (DOT) at facility A and facility A did not have the personnel needed to provide daily patient transport to the PRDH clinic. VDOT uses video and computer equipment that allows public health officials to observe patients taking medications for TB, and it has been successfully used to ensure proper completion of TB treatment (2–5). A standard live VDOT protocol (e.g., using FaceTime) (4) was attempted at facility A but was not sustainable because cell phones or Internet connectivity were not consistently available. An asynchronous VDOT protocol that did not require real-time Internet connection or a cellular plan, complied with the Health Insurance Portability and Accountability Act, and provided a Spanish external-facing application*,† was implemented to ensure proper treatment for TB and LTBI patients. Use of this asynchronous system avoided audio/visual interruption related to poor connectivity, which can be problematic in standard live VDOT applications (4), by capturing and storing videos of patients as they swallowed their TB medications, and automatically uploading the videos after Internet connection became available. Videos were viewed by PRDH staff members at 2–10 times the speed at which they were recorded. In addition to the clinic-to-facility commute, which would have taken 1.5 hours per day, DOT for the 17 severely cognitively challenged men would have required an additional 1.5 hours per day of observation. Use of asynchronous VDOT saved PRDH approximately 240 hours in DOT-related activities, equivalent to 25% of the workload for a full-time epidemiology technician/case manager over 6 months of treatment. As of July 12, 2017, all 11 patients with active TB disease and all six with LTBI had completed treatment with recommended ≥80% compliance (percentage of scheduled doses actually taken) (Table) (6). Active TB disease treatment rates were higher than those for LTBI because protocols exist for