WHAT YOU DON’T KNOW ABOUT ZIKA VIRUS

Preliminary Findings from an Investigation of Zika Virus Infection in a Patient with No Known Risk Factors — Utah, 2016

On July 12, 2016, the Utah Department of Health (UDOH) was notified by a clinician caring for an adult (patient A) who was evaluated for fever, rash, and conjunctivitis that began on July 1. Patient A had not traveled to an area with ongoing Zika virus transmission; had not had sexual contact with a person who recently traveled; and had not received a blood transfusion, organ transplant, or mosquito bites (1). Patient A provided care over several days to an elderly male family contact (the index patient) who contracted Zika virus abroad. The index patient developed septic shock with multiple organ failure and died in the hospital on June 25, 2016. The index patient’s blood specimen obtained 2 days before his death had a level of viremia approximately 100,000 times higher than the average level reported in persons infected with Zika virus (2). Zika virus infection was diagnosed in patient A by real-time reverse transcription–polymerase chain reaction (rRT-PCR) testing on a urine specimen collected 7 days after symptom onset. In addition, a serum specimen collected 11 days after symptom onset, after patient A’s symptoms had resolved, was positive for antibodies to Zika virus by Zika immunoglobulin M (IgM) capture enzyme-linked immunosorbent assay (MAC-ELISA) and had neutralizing antibodies detected by plaque-reduction neutralization testing (PRNT). Working with Salt Lake and Davis County Health Departments, UDOH requested assistance from CDC with an investigation to determine patient A’s exposures and determine a probable source of infection.

The investigation consisted of four components: 1) an epidemiologic evaluation of family contacts of the index patient, 2) a serosurvey of health care workers who provided direct care to the index patient before his death, 3) a community serosurvey around the locations where the index patient had resided, and 4) active vector surveillance near the residences of the index patient and patient A. For the purpose of this investigation, a family contact was defined as a person who resided in the same household as the index patient or had direct contact with his body fluids (i.e., tears, conjunctival discharge, saliva, vomitus, urine, or stool) during the period when he was most likely viremic, including a few days before his illness onset and until his death.

Nineteen family contacts, including patient A, were identified and interviewed, and provided blood or urine specimens for testing. Thirteen family contacts reported hugging and kissing the index patient’s face. Five family contacts reported being present while the index patient’s stool, urine, or vomitus was being cleaned. Patient A reported hugging and kissing the index patient, in a similar fashion to other family contacts, and assisted hospital personnel in holding the index patient while his stool was being cleaned, but did not have direct contact with stool. Other than patient A, all family contacts were negative for Zika virus infection by rRT-PCR or MAC-ELISA on specimens obtained roughly 2–3 weeks after last exposure.

Health care workers who provided care to the index patient and residents living within a 200-meter radius of the two homes where the index patient resided before becoming hospitalized were interviewed to assess risk factors for Zika virus infection and were offered Zika virus testing. As of August 22, 86 health care worker contacts have been identified and interviewed to assess types of patient interactions and to quantify level of exposure to the index patient’s body fluids. A total of 238 households were approached, and all available and consenting household members were interviewed using a standardized questionnaire about risk factors for mosquito-borne transmission. All health care workers and community members who provided blood specimens are being tested for Zika virus IgM antibodies using a MAC-ELISA. Urine specimens were also collected from any persons who reported Zika virus-like symptoms in the 14 days before their interview. Testing is incomplete, but as of August 22 it has not revealed any persons with Zika virus infections.

Local mosquito abatement districts worked in collaboration with vector entomologists from CDC to conduct larval and adult mosquito surveillance near the index patient’s and patient A’s residences. Door-to-door surveys around neighborhood homes were conducted and a variety of mosquito traps (e.g., Biogents Sentinel, gravid, light traps baited with carbon dioxide, and ovitraps) were deployed. Larval specimens obtained in the field were reared to the adult stage for identification. Adult mosquitoes are in the process of being identified and tested for Zika virus RNA by rRT-PCR, but no Aedes aegypti or Aedes albopictus mosquitoes have been identified as part of this investigation.

It remains unclear how patient A was infected; however patient A was known to have had close contact (i.e. kissing and hugging) with the index patient while the index patient’s viral load was found to be very high. Although it is not certain that these types of close contact were the source of transmission, family contacts should be aware that blood and body fluids of severely ill patients might be infectious. Given recognition of high levels of viremia during illness, it is essential that health care workers continue to apply standard precautions while caring for all patients, including those who might have Zika virus disease (3).

Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov.
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Zika virus

 

Zika is a virus that is closely related to dengue. It is spread by mosquitoes. Zika virus was first found in 1947 and in Asia in 1969. However it may have been in these areas for much longer.

Zika virus was first reported outside Africa and Asia in 2007 where it caused an outbreak in Yap State (Federated States of Micronesia). Between 2013 and 2015 there were large outbreaks of Zika virus in the Pacific Islands, and in 2015, Zika virus emerged in South America, with spread to many countries in South and Central America and the Caribbean. Zika virus outbreaks are ongoing in the Americas and Pacific Islands.

Refer to the Department of Health webpage for the list of affected countries.

There is evidence of small numbers of cases of Zika virus reported in Southeast Asian countries such as Thailand, Papua New Guinea and Indonesia.

Symptoms

If someone is infected with Zika virus, it can typically take 3 to 12 days for symptoms to appear.

Approximately one person in five who catches Zika virus is likely to feel sick, and if they do, the disease is generally not severe and lasts only a few days. Symptoms may be similar to those caused by the flu and can include:

  • Fever;
  • a skin rash;
  • pain in the joints;
  • muscle pain;
  • a headache, especially with pain behind the eyes;
  • conjunctivitis (red eyes); and
  • weakness or lack of energy.

Most people experience a very mild infection without any complications. However, recent outbreaks of Zika virus in the Pacific and the Americas show that Zika virus can be passed from a woman to her unborn baby. This can cause potentially serious consequences in the baby, in particular a condition called microcephaly (a small head and brain) and other birth defects.

There is also strong scientific agreement that Zika virus can cause a rare paralysing condition called Guillain-Barré Syndrome (GBS). This condition has been found in areas where Zika virus outbreaks are occurring and in cases of individual travellers returning from affected countries. GBS is known to be caused by other viruses and bacteria as well.

How it spreads

Zika virus is spread by the bite of a mosquito that is carrying the virus. Not all types of mosquitoes can spread it. Some types of Aedes mosquito can spread Zika virus, particularly Aedes aegypti but also possibly Aedes albopictus. Both are daytime biting mosquitoes, with increased activity around sunrise and sunset. Aedes aegypti mosquitoes often live in and around buildings in urban areas.

Most areas of Australia do not have the Aedes aegypti mosquito that can carry the virus. This mosquito is currently found in parts of Northern, Central and Southwest Queensland.  Aedes albopictus is found in the Torres Strait Islands. Therefore, in most parts of Australia, there is no risk of Zika virus being spread by mosquitoes. Currently, all cases of Zika virus diagnosed in Australia were caught overseas.

Occasionally, Zika virus can also spread through sexual activity (vaginal, oral, or anal). However, the main way that Zika virus spreads is still by mosquitoes.

People at risk

People living in or visiting countries that are affected by Zika virus are at increased risk of Zika virus infection. Refer to the Department of Health pagefor a list of Zika virus affected countries.

High risk countries are currently experiencing widespread transmission of Zika virus. There is a high risk of travellers getting a Zika virus infection.

Moderate risk countries have sporadic cases of Zika virus infection occurring. Zika virus is present and may be reported in travellers, however it is not widespread, and the risk of travellers getting a Zika virus infection is thought to be lower than countries with widespread Zika virus.

Low risk countries have not recently reported Zika virus but it has been present in the past. There is a possibility of very low levels of Zika virus being present or occurring in the future. The risk is low but not zero.

Pregnant women should undertake an individual risk assessment with a doctor prior to making travel decisions. Pregnant women and their unborn babies are at particular risk of serious consequences of Zika virus infection. Preventing infection is essential. It is recommended that pregnant women or women planning a pregnancy defer travel to high risk countries. They should consider deferring travel to moderate risk countries. Travel to low risk countries by pregnant women can be considered following an individual risk assessment with a doctor. If they do decide to travel to a Zika-affected country, please see Preventing infection. Those planning pregnancy should defer pregnancy until at least 8 weeks after return. If their male partner is diagnosed with a Zika virus infection, pregnancy should be deferred for at least 6 months.

Preventing infection

There is no vaccine for Zika virus infection. Prevention relies on avoiding being bitten by mosquitoes in countries where Zika virus occurs.Safe sex practices are also important in preventing sexual transmission.

How do I protect myself from mosquitoes?

All travellers should follow recommendations to avoid mosquito bites at all times when travelling in overseas countries where there is a risk of mosquito-borne diseases to reduce their risk of catching Zika virus. This is particularly important if you are pregnant or planning a pregnancy.

It is important to be aware that these precautions are necessary in the daytime and night time:

  • Cover as much exposed skin as possible, including wearing light coloured long-sleeved shirts and long pants;
  • Use insect repellents, applied according to the product label. The most effective mosquito repellents contain Diethyl Toluamide (DEET) or Picaridin. Repellents containing oil of lemon eucalyptus (OLE) (also known as Extract of Lemon Eucalyptus) or para menthane diol (PMD) also provide adequate protection. Note that insect repellents containing DEET or Picaridin, are safe for pregnant and breastfeeding women and children older than 2 months when used according to the product label. If you use both sunscreen and insect repellent, apply the sunscreen first and then the repellent;
  • Use insecticide-treated (such as Permethrin) clothing and gear (such as boots, pants, socks, and tents); and
  • Stay and sleep in screened-in or air-conditioned rooms. Use bed nets if you cannot keep mosquitoes from coming inside the room.

Seek medical advice, as soon as practicable, if unwell during or soon after travel.

How can sexual transmission of Zika virus be prevented?

Avoid unprotected sex while travelling in high or moderate risk a Zika virus affected country, and for at least 8 weeks after your return. This may be longer if an infection is diagnosed. Men or women who have travelled to a Zika virus affected country who have a pregnant partner should avoid unprotected sex (vaginal, oral, or anal) for the duration of the pregnancy. An individual risk assessment completed with your doctor can help you make decisions about what to do if you are unable to practice safe sex for 8 weeks after return from a Zika virus affected country.

Please see your doctor for further advice.

How Zika virus infection is diagnosed

A blood or urine test can diagnose Zika virus infection.

For further information on testing, please refer to Information on testing for Zika virus infection.

How Zika virus infection is treated

At the moment there is no specific treatment for Zika virus infection, but supportive medical care can be provided if required (e.g. rest, fluids).

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Preventing Zika virus spread in Australia

Health authorities prevent the spread of Zika virus in Australia by:

  • In areas of Queensland where the mosquitoes Aedes aegypti and/or Aedes albopictus are present, health authorities will respond urgently to cases to prevent it from spreading in Australia, as they do for cases of dengue. This will include advising people on avoiding mosquito bites during their illness and may include controlling mosquitoes around the person’s home;
  • Continuing to monitor international ports of entry to prevent the mosquitoes that can transmit Zika virus from entering or spreading to new areas; and
  • Ensuring the safety of the blood supply through restrictions on whole blood donation for travellers coming to Australia from areas where mosquito-borne diseases are occurring.

What should I do if I think I might have Zika virus?

If you have returned within the last two weeks from travel to a Zika virus affected country and become unwell, you should see a doctor and mention your overseas travel.

All pregnant women who have travelled to a Zika virus affected country should see their doctor. Testing for Zika virus can be discussed depending on your individual risk assessment.

Women who have travelled to a high or moderate risk Zika virus affected country should not attempt to become pregnant for at least 8 weeksfollowing the last day they were in a Zika virus affected country. Those who have travelled to low risk countries should have an individual risk assessment.

If you or your partner travelled to a Zika virus affected country, you may need to avoid unprotected sex (vaginal, oral, anal) for at least 8 weeks after your return. This may be longer if an infection is diagnosed. Men and women with a pregnant partner should avoid unprotected sex (vaginal, oral, or anal) for the duration of the pregnancy.

Can I still donate blood?

People who have been to Zika virus affected country should not donate whole blood for 4 weeks after they have returned.

If you are confirmed by a doctor to have Zika virus infection, you should not donate whole blood for 4 weeks after symptoms have disappeared.

If you have had had sex with someone who has been diagnosed with Zika virus infection at any time in the last 3 months, you should not donate whole blood for 4 weeks after the last time you had sex with that person.

Can I still donate sperm?

Men returning from Zika virus affected countries should wait at least 8 weeks upon return before donating sperm.

Men who have had a confirmed Zika virus infection should wait 6 months following diagnosis before donating sperm

Hematuria (Blood in the U

Hematuria (Blood in the Urine)

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What is hematuria?

Hematuria is the presence of blood in a person’s urine. The two types of hematuria are

  • gross hematuria—when a person can see the blood in his or her urine
  • microscopic hematuria—when a person cannot see the blood in his or her urine, yet it is seen under a microscope

Illustrations of a male and female torso showing the respective urinary tracts.
The male and female urinary tracts

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What is the urinary tract?

The urinary tract is the body’s drainage system for removing wastes and extra fluid. The urinary tract includes

  • two kidneys
  • two ureters
  • the bladder
  • the urethra

The kidneys are two bean-shaped organs, each about the size of a fist. They are located just below the rib cage, one on each side of the spine. Every day, the kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2 quarts of urine, composed of wastes and extra fluid. Children produce less urine than adults. The urine flows from the kidneys to the bladder through tubes called ureters. The bladder stores urine until releasing it through urination. When the bladder empties, urine flows out of the body through a tube called the urethra at the bottom of the bladder.

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What causes hematuria?

Reasons people may have blood in the urine include

  • infection in the bladder, kidney, or prostate
  • trauma
  • vigorous exercise
  • viral illness, such as hepatitis—a virus that causes liver disease and inflammation of the liver
  • sexual activity
  • menstruation
  • endometriosis—a problem in women that occurs when the kind of tissue that normally lines the uterus grows somewhere else, such as the bladder

More serious reasons people may have hematuria include

  • bladder or kidney cancer
  • inflammation of the kidney, urethra, bladder, or prostate—a walnut-shaped gland in men that surrounds the urethra and helps make semen
  • blood-clotting disorders, such as hemophilia
  • sickle cell disease—a genetic disorder in which a person’s body makes abnormally shaped red blood cells
  • polycystic kidney disease—a genetic disorder in which many cysts grow on a person’s kidneys

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Who is more likely to develop hematuria?

People who are more likely to develop hematuria may

  • have an enlarged prostate
  • have urinary stones
  • take certain medications, including blood thinners, aspirin and other pain relievers, and antibiotics
  • do strenuous exercise, such as long-distance running
  • have a bacterial or viral infection, such as streptococcus or hepatitis
  • have a family history of kidney disease
  • have a disease or condition that affects one or more organs

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What are the symptoms of hematuria?

People with gross hematuria have urine that is pink, red, or brown. Even a small amount of blood in the urine can cause urine to change color. In most cases, people with gross hematuria do not have other signs and symptoms. People with gross hematuria that includes blood clots in the urine may have bladder pain or pain in the back.

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How is hematuria diagnosed?

A health care professional diagnoses hematuria or the cause of the hematuria with

  • a medical history
  • a physical exam
  • urinalysis
  • additional testing

Medical History

Taking a medical history may help a health care professional diagnose the cause of hematuria. He or she will ask the patient to provide a medical history, a review of symptoms, and a list of prescription and over-the-counter medications. The health care professional will also ask about current and past medical conditions.

Physical Exam

During a physical exam, a health care professional most often taps on the abdomen and back, checking for pain or tenderness in the bladder and kidney area. A health care professional may perform a digital rectal exam on a man to look for any prostate problems. A health care professional may perform a pelvic exam on a woman to look for the source of possible red blood cells in the urine.

Digital rectal exam. A digital rectal exam is a physical exam of a man’s prostate and rectum. To perform the exam, the health care professional has the man bend over a table or lie on his side while holding his knees close to his chest. The health care professional slides a gloved, lubricated finger into the patient’s rectum and feels the part of the prostate that lies in front of the rectum. The digital rectal exam is used to check for prostate inflammation, an enlarged prostate, or prostate cancer.

Pelvic exam. A pelvic exam is a visual and physical exam of a woman’s pelvic organs. The health care professional has the woman lie on her back on an exam table and place her feet on the corners of the table or in supports. The health care professional looks at the pelvic organs and slides a gloved, lubricated finger into the vagina to check for problems that may be causing blood in the urine.

Urinalysis

The health care professional can test the urine in the office using a dipstick or can send it out to a lab for analysis. Sometimes urine tests using a dipstick can be positive even though the patient has no blood in the urine, which results in a “false-positive” test. The health care professional may look for red blood cells by examining the urine under a microscope before ordering further tests.

Prior to obtaining a urine sample, the health care professional may ask a woman when she last menstruated. Sometimes blood from a woman’s menstrual period can get into her urine sample and can result in a false-positive test for hematuria. The test should be repeated after the woman stops menstruating.

Image of a lab technician analyzing viles of red blood cells
The health care professional may confirm the presence of red blood cells by examining the urine under a microscope before ordering further tests.

Additional Testing

Sometimes, a health care professional will test the patient’s urine again. If the urine samples detect too many red blood cells, a health care professional may order additional tests:

  • Blood test. A blood test involves drawing blood at a health care professional’s office or a commercial facility and sending the sample to a lab for analysis. A blood test can detect high levels of creatinine, a waste product of normal muscle breakdown, which may indicate kidney disease. Other blood tests may detect signs of autoimmune diseases, such as lupus, or other diseases, such as prostate cancer, which can cause hematuria.
  • Computed tomography (CT) scan. CT scans use a combination of x-rays and computer technology to create images of the urinary tract, especially the kidneys. A health care professional may give the patient a solution to drink and an injection of contrast medium. CT scans require the patient to lie on a table that slides into a tunnel-shaped device that takes the x-rays. An x-ray technician performs the procedure in an outpatient center or a hospital, and a radiologist interprets the images. The patient does not need anesthesia. CT scans can help a doctor diagnose stones in the urinary tract, obstructions, infections, cysts, tumors, and traumatic injuries.
  • Cystoscopy. Cystoscopy is a procedure that a urologist—a doctor who specializes in urinary problems—performs to see inside the patient’s bladder and urethra using a cystoscope, a tubelike instrument. The health care professional performs cystoscopy in his or her office, in an outpatient center, or in a hospital. The patient may need pain medication. A cystoscopy can detect cancer in a patient’s bladder.
  • Kidney biopsy. Kidney biopsy is a procedure that involves taking a small piece of tissue from the kidney. A health care professional performs the biopsy in an outpatient center or a hospital. The health care professional will give the patient light sedation and local anesthetic. In some cases, the patient will require general anesthesia. A pathologist—a doctor who specializes in diagnosing diseases—examines the tissue in a lab. The biopsy can help diagnose if the hematuria is due to kidney disease.
  • Magnetic resonance imaging (MRI). MRI is a test that takes pictures of the patient’s internal organs and soft tissues without using x-rays. A specially trained technician performs the procedure in an outpatient center or a hospital, and a radiologist interprets the images. The patient does not need anesthesia, although patients with a fear of confined spaces may receive light sedation. An MRI may include the injection of contrast medium. With most MRI machines, the patient will lie on a table that slides into a tunnel-shaped device that may be open-ended or closed at one end. Some machines allow the patient to lie in a more open space. During an MRI, the patient should remain perfectly still while the technician takes the images. During the procedure, the patient will hear loud mechanical knocking and humming noises coming from the machine. An MRI can help diagnose problems in individual internal organs, such as the bladder or kidney.

More information is provided in the NIDDK health topic, Imaging of the Urinary Tract.

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How is hematuria treated?

Health care professionals treat hematuria by treating its underlying cause. If no serious condition is causing a patient’s hematuria, he or she typically does not need treatment.

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Eating, Diet, and Nutrition

Researchers have not found that eating, diet, and nutrition play a role in causing or preventing hematuria.

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Points to Remember

  • Hematuria is the presence of blood in a person’s urine. Gross hematuria is when a person can see the blood in his or her urine, and microscopic hematuria is when a person cannot see the blood in his or her urine, yet a health care professional can see it under a microscope.
  • The causes of hematuria include vigorous exercise and sexual activity, among others.
  • More serious causes of hematuria include kidney or bladder cancer; inflammation of the kidney, urethra, bladder, or prostate; and polycystic kidney disease, among other causes.
  • People who are more likely to develop hematuria may have a family history of kidney disease, have an enlarged prostate, or have bladder or kidney stones, among other reasons.
  • People with gross hematuria have urine that is pink, red, or brown.
  • Most people with microscopic hematuria do not have any symptoms.
  • Taking a medical history may help a health care professional diagnose the cause of hematuria.
  • Health care professionals diagnose hematuria with a urine test called urinalysis.
  • If two of three urine samples detect too many red blood cells, a health care professional may order one or more additional tests.
  • Health care professionals treat hematuria by treating its underlying cause.
  • Researchers have not found that eating, diet, and nutrition play a role in causing or preventing