Management of infection by the Zika virus

Falcao et al. Ann Clin Microbiol Antimicrob (2016) 15:57 DOI 10.1186/s12941-016-0172-y Annals of Clinical Microbiology and Antimicrobials Open Access REVIEW Management of infection by the Zika virus Melissa Barreto Falcao1, Sergio Cimerman2, Kleber Giovanni Luz3, Alberto Chebabo4, Helena Andrade Brigido5, Iza Maria Lobo6, Artur Timerman7, Rodrigo Nogueira Angerami8, Clovis Arns da Cunha9, Helio Arthur Bacha10, Jesse Reis Alves2, Alexandre Naime Barbosa11, Ralcyon Francis Teixeira2, Leonardo Weissmann2, Priscila Rosalba Oliveira12*, Marco Antonio Cyrillo13 and Antonio Carlos Bandeira14 Abstract A panel of national experts was convened by the Brazilian Infectious Diseases Society in order to organize the national recommendations for the management of zika virus infection. The focus of this document is the diagnosis, both clinical and laboratorial, and appropriate treatment of the diverse manifestations of this infection, ranging from acute mild disease to Guillain-Barré syndrome and also microcephaly and congenital malformations. Keywords: Zika virus infection, Guideline, Diagnosis, Therapeutics Background The Zika virus is an arbovirus of the genus Flavivirus, in the family Flaviviridae, which was first identified in 1947, in the Zika Forest in Uganda during a monitoring program on wild yellow fever [1–4]. It is related to other flaviviruses, including the viruses that cause dengue, yellow fever and West Nile fever. Outbreaks of the disease were first notified in the Pacific region in 2007 and 2013, respectively in the Yap islands and in French Polynesia, and then in the Americas (Brazil and Colombia) and in Africa (Cape Verde) in 2015 [2, 3, 5, 6]. Rapid geographical expansion has been observed since then, with 40 countries in the Americas reporting autochthonous transmission as sporadic cases or outbreaks. It is also important to mention the growing number of countries on other continents that have been notifying occurrences of imported cases of Zika virus infection, thus demonstrating its great potential for dissemination on a worldwide scale [7]. Through occurrences of Zika outbreaks, the central nervous system and autoimmune complications that *Correspondence: 12 Universidade de São Paulo, Rua Doutor Ovidio Pires de Campos, 333, Sao Paulo, SP CEP 05403‑010, Brazil Full list of author information is available at the end of the article were previously reported in French Polynesia have also come to be observed in the Americas. Zika infection during pregnancy has been correlated with congenital microcephaly, fetal malformations and fetal losses. This led the Brazilian Ministry of Health to declare a state of public health emergency of national importance in November 2015, after observation of changes to the epidemiological pattern of occurrences of microcephaly in Pernambuco and other states in northeastern Brazil [8, 9]. In the light of the significant increase in the incidence of neurological syndromes and cases of microcephaly that were potentially related to the Zika virus, the World Health Organization (WHO) declared an international public health state of emergency in February 2016. To put the importance of this event into context, this was the fourth time that WHO has ever declared a worldwide state of emergency in relation to a viral epidemic. The previous decisions were made in relation to H1N1 (2009), poliomyelitis (2014) and Ebola (2014). On February 18, 2016, the Brazilian Ministry of Health issued an ordinance that made it compulsory to notify suspected cases of Zika throughout the country. This disease has thus been added to other arboviruses, such as dengue, yellow fever, West Nile fever and chikungunya, © 2016 The Author(s). This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Falcao et al. Ann Clin Microbiol Antimicrob (2016) 15:57 which were already on the national list of diseases with compulsory notification [10]. Epidemiology Geographical distribution In humans, the Zika virus was first identified in Uganda and Tanzania, in 1952 [11]. Between 1952 and 1981, a variety of serological evidence regarding infection by this virus was reported from countries in Africa and some parts of Asia [4]. The first epidemic outside of Africa and Asia occurred in 2007, in the Yap islands of Micronesia. It was estimated that more than 70 % of the population over the age of 3 years became infected [2]. Another large outbreak of Zika fever occurred concomitantly with a dengue epidemic (serotypes 1 and 3) in French Polynesia in 2013– 2014, affecting around 32,000 people [3]. In 2014, cases of Zika virus infection were reported on Easter Island, which is Chilean territory [12]. In May 2015, some months after reports of increased incidence of exanthematous febrile disease in states of northeastern Brazil, which until then were of unidentified cause, presence of Zika virus circulation was confirmed in this country. This was initially confirmed in Bahia on April 29, 2015, from analysis on samples from patients with an exanthematous condition in Camaçari, Bahia, and subsequently in Rio Grande do Norte on May 9, 2015, with identification of the Asian genotype [13, 14]. Also in May, cases in Sumaré and Campinas (São Paulo), Maceió (Alagoas) and Belém (Pará) were confirmed through laboratory tests. Since then, rapid expansion of the areas of circulation and autochthonous transmission of the virus has been observed, notably in states of the northeastern region of Brazil. It is estimated that more than one million Brazilians became infected with the Zika virus in 2015, thus reflecting the capacity of the virus to cause large-scale outbreaks in places where the biological vector is present. Worldwide, the virus is now circulating in 65 countries and territories, mostly in the Americas [15]. Transmission methods Zika is transmitted primarily through the bites of infected mosquitos of the genus Aedes, especially Aedes aegypti and Aedes albopictus [16]. In humans, except for pregnant women, the period of viremia is short and it is most frequently identified by the 5th day after the symptoms start. The RNA of the Zika virus has been identified in blood as early as on the 1st day, and also only up to 11 days after the disease begins. Prolonged Zika virus RNA was detected in serum of four symptomatic pregnant women in up to 46 days after Page 2 of 15 symptoms onset and in one asymptomatic pregnant woman 53 days after infection [17]. In pregnant women Zika (...truncated)