Zika Virus Guidelines

Updated: Oct 12, 2017
  • Author: Bhagyashri D Navalkele, MD, MBBS; Chief Editor: Michael Stuart Bronze, MD  more...
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Guidelines

Guidelines Summary

Prevention

Travel Advisories

Updates on areas with ongoing Zika virus transmission are available online (http://wwwnc.cdc.gov/travel/notices/). Mosquitoes that spread Zika virus usually do not live at elevations above 6,500 feet (2,000 meters). People who live in or visit areas above this elevation are at a very low risk of acquiring Zika virus from a mosquito unless they visit or travel through areas of lower elevation. [30]  

Prevention of Mosquito Bites

The CDC recommends that all residents of and visitors to areas where Zika virus is spreading take the following steps to prevent mosquito bites: [30]

  • Cover exposed skin by wearing long-sleeved shirts and long pants.
  • Use insect repellents that are registered with the Environmental Protection Agency (EPA) and contain DEET, picaridin, oil of lemon eucalyptus, para-menthane-diol, or IR3535. Always use as directed.
  • Use permethrin-treated clothing and gear (boots, pants, socks, tents).
  • Stay and sleep in screened-in or air-conditioned rooms.
  • Sleep under a mosquito bed net if air conditioned or screened rooms are not available or if sleeping outdoors.
  • Mosquito netting can be used to cover babies younger than 2 months in carriers, strollers, or cribs to protect them from mosquito bites.

Prevention of Sexual Transmission

In July 2016, the CDC updated its recommendations for the prevention of sexual transmission of Zika virus. The updated recommendations include the following: [24]

  • Pregnant women with sex partners (male or female) who live in or have traveled to an area with active Zika virus transmission should use barriers against infection during sex or abstain from sex for the duration of the pregnancy.
  • Couples in which a partner had confirmed Zika virus infection or clinical illness consistent with Zika virus disease should consider using barrier methods against infection or abstain from sex, as follows:
    • Men with Zika virus infection, for at least 6 months after onset of illness
    • Women with Zika virus infection, for at least 8 weeks after onset of illness
  • Couples in which one partner traveled to or resides in an area with active Zika virus transmission but did not develop symptoms of Zika virus disease should consider using barrier methods against infection or abstaining from sex for at least 8 weeks after that partner returned from the Zika-affected area.
  • Couples who reside in an area with active Zika virus transmission might consider using barrier methods against infection or abstaining from sex while active transmission persists.

Virus Transmission by Blood and Blood Components 

In August 2016, the FDA revised its guidelines for reducing the risk of Zika virus transmission via blood and blood components. The key recommendations included the following: [31]

  • All blood donations should be tested with an investigational individual donor nucleic acid test (ID-NAT) for Zika virus under an investigational new drug application (IND) or, when available, a licensed test
  • Implement pathogen reduction technology for platelets and plasma using an FDA-approved pathogen-reduction device
  • Providing donor educational material with respect to Zika virus and screening donors for Zika virus risk factors, such as travel history, and deferring them as previously recommended in the February 2016 guidance is no longer necessary
  • If a potential donor volunteers a recent history of Zika virus infection, blood or blood components should not be collected. The donor should be deferred for 120 days after a positive viral test or the resolution of symptoms, whichever timeframe is longer.
  • ID-NAT–nonreactive donations may be released provided all other donation suitability requirements are met
  • ID-NAT–reactive donations may not be used
  • Defer a donor who tests ID-NAT reactive for 120 days from the date of the reactive test or after the resolution of Zika virus symptoms, whichever timeframe is longer. Notify donors of the deferral and counsel them regarding possible Zika virus infection.
  • Quarantine and retrieve blood and blood components collected 120 days prior to the donor's ID-NAT–reactive donation. If the prior blood components were transfused, advise the transfusion service to inform the transfusion recipient’s physician of record regarding the potential need for monitoring and counseling the recipient for possible Zika virus infection. 
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Zika Virus Testing

The CDC offers the following recommendations for Zika virus testing:

  • Testing of specimens to assess risk of sexual transmission is not recommended. [24]
  • Individuals who have had possible sexual exposure to Zika virus and who develop signs or symptoms consistent with Zika virus disease should be tested. [24]
  • All pregnant women should be tested if they have had possible exposure to Zika virus, including sexual exposure. [24]
  • Real-time reverse transcription-polymerase chain reaction (rRT-PCR) is the preferred test for Zika virus infection because it can be performed rapidly and is highly specific when performed on urine collected less than 14 days after  symptom onset. [20]
  • Zika virus rRT-PCR testing of urine should be performed in conjunction with serum testing if using specimens collected less than 7 days after symptom onset. [20]
  • Because a negative rRT-PCR result does not exclude infection, immunoglobulin M (IgM) and neutralizing antibody testing should be performed to identify additional recent Zika virus infections. [23]  
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CDC Guidelines on Zika Testing in Pregnancy

Guidelines on Zika testing in pregnancy by the Centers for Disease Control and Prevention are as follows: [40, 41]

  • Screen pregnant women for risk of Zika virus exposure and symptoms of Zika virus infection. Promptly test pregnant women with Zika virus nucleic acid test (NAT) if they become symptomatic during their pregnancy or if a sexual partner tests positive for Zika virus infection.
  • Consider NAT testing at least once per trimester, unless a previous test has been positive.
  • Consider NAT testing of amniocentesis specimens if amniocentesis is performed for other reasons.
  • Counsel pregnant women each trimester on the limitations of IgM and NAT testing.
  • Consider IgM testing to determine baseline Zika virus IgM levels as part of preconception counseling.
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Pregnancy

Preconception 

The CDC makes the following recommendations to individuals considering conception after exposure to the Zika virus: [26]

  • Women with Zika virus disease should wait until at least 8 weeks after symptom onset before attempting conception.
  • Asymptomatic men and women should wait at least 8 weeks after the last date of possible exposure before attempting conception.
  • Men with Zika virus disease should wait at least 6 months after symptom onset before attempting conception.

Asymptomatic women and men who reside in an area with active Zika virus transmission and are planning to become pregnant should discuss the risks for active Zika virus transmission with their healthcare providers, and providers should discuss their patients’ reproductive life plans in the context of potential Zika virus exposure. [26]

Testing for evidence of Zika virus infection should be performed in persons with possible exposure to Zika virus who have one or more of the following symptoms within 2 weeks of possible exposure:

  • Acute onset of fever
  • Rash
  • Arthralgia
  • Conjunctivitis

Routine testing is not recommended for asymptomatic women or men with exposure to Zika virus who are attempting conception.

Pregnant Women

The CDC recommends that all pregnant women consider postponing travel to areas with active Zika virus transmission. [21]

If a pregnant woman travels to an area with Zika virus transmission, she should be advised to strictly follow recommended steps to avoid mosquito bites throughout the entire day. When used as directed, insect repellents containing DEET, picaridin, and IR3535 are safe for pregnant women. [21]

Pregnant women with a history of travel to an area with Zika virus transmission with two or more of the following symptoms within 2 weeks of travel or who have ultrasound findings of fetal microcephaly or intracranial calcifications should be tested for Zika virus infection:

  • Acute onset of fever
  • Rash
  • Arthralgia
  • Conjunctivitis 

The CDC recommends Zika nucleic acid testing three times during pregnancy among women with ongoing potential Zika virus exposure. They no longer recommend routine immunoglobulin antibody testing in asymptomatic women, since immunoglobulin M (IgM) antibodies may persist more than 12 weeks, complicating differentiation between infections that began before pregnancy from infections that began during pregnancy.

The CDC also recommends that all pregnant women and women who are planning pregnancy be asked about potential Zika exposure at every prenatal visit. [32]

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Congenital Zika Virus Infection

In August 2016, the CDC released an update to its Interim Guidance for the Evaluation and Management of Infants with Possible Congenital Zika Virus Infection, which contained the major recommendations below. [33]

Infants born to mothers with laboratory evidence of Zika virus infection during pregnancy, as well as those with abnormal clinical or neuroimaging findings suggestive of congenital Zika syndrome and evidence suggesting possible transmission, regardless of maternal Zika virus test results, should undergo testing.

Initial evaluation includes the following:

  • Both molecular (rRT-PCR) and serologic (IgM) testing; initial samples should be collected directly from the infant in the first 2 days of life, if possible
  • Comprehensive physical examination, including a neurologic examination, postnatal head ultrasonography, and standard newborn hearing screen

Infants with laboratory evidence of congenital Zika virus infection should undergo comprehensive ophthalmologic examination and hearing assessment via auditory brainstem response (ABR) testing before age 1 month.

Follow-up of infants with abnormalities consistent with congenital Zika syndrome should be conducted via coordinated evaluation by multiple specialists within the first month of life; additional evaluations will be needed within the first year of life, including assessments of vision, hearing, feeding, growth, and neurodevelopmental and endocrine function.

Infants without apparent abnormalities should undergo ongoing developmental monitoring and screening by the primary care provider, including repeat hearing testing.

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