Update: Interim Guidance for Health Care Providers Caring for Pregnant Women With Possible Zika Virus Exposure — United States, July 2016

Titilope Oduyebo, MD; Irogue Igbinosa, MD; Emily E. Petersen, MD; Kara N.D. Polen, MPH; Satish K. Pillai, MD; Elizabeth C. Ailes, PhD; Julie M. Villanueva, PhD; Kim Newsome, MPH; Marc Fischer, MD; Priya M. Gupta, MPH; Ann M. Powers, PhD; Margaret Lampe, MPH; Susan Hills, MBBS; Kathryn E. Arnold, MD; Laura E. Rose, MTS; Carrie K. Shapiro-Mendoza, PhD; Charles B. Beard, PhD; Jorge L. Muñoz, PhD; Carol Y. Rao, ScD; Dana Meaney-Delman, MD; Denise J. Jamieson, MD; Margaret A. Honein, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2016;65 

In This Article

Abstract and Introduction

Abstract

CDC has updated its interim guidance for U.S. health care providers caring for pregnant women with possible Zika virus exposure, to include the emerging data indicating that Zika virus RNA can be detected for prolonged periods in some pregnant women. To increase the proportion of pregnant women with Zika virus infection who receive a definitive diagnosis, CDC recommends expanding real-time reverse transcription–polymerase chain reaction (rRT-PCR) testing. Possible exposures to Zika virus include travel to or residence in an area with active Zika virus transmission, or sex* with a partner who has traveled to or resides in an area with active Zika virus transmission without using condoms or other barrier methods to prevent infection. Testing recommendations for pregnant women with possible Zika virus exposure who report clinical illness consistent with Zika virus disease§ (symptomatic pregnant women) are the same, regardless of their level of exposure (i.e., women with ongoing risk for possible exposure, including residence in or frequent travel to an area with active Zika virus transmission, as well as women living in areas without Zika virus transmission who travel to an area with active Zika virus transmission, or have unprotected sex with a partner who traveled to or resides in an area with active Zika virus transmission). Symptomatic pregnant women who are evaluated <2 weeks after symptom onset should receive serum and urine Zika virus rRT-PCR testing. Symptomatic pregnant women who are evaluated 2–12 weeks after symptom onset should first receive a Zika virus immunoglobulin (IgM) antibody test; if the IgM antibody test result is positive or equivocal, serum and urine rRT-PCR testing should be performed. Testing recommendations for pregnant women with possible Zika virus exposure who do not report clinical illness consistent with Zika virus disease (asymptomatic pregnant women) differ based on the circumstances of possible exposure. For asymptomatic pregnant women who live in areas without active Zika virus transmission and who are evaluated <2 weeks after last possible exposure, rRT-PCR testing should be performed. If the rRT-PCR result is negative, a Zika virus IgM antibody test should be performed 2–12 weeks after the exposure. Asymptomatic pregnant women who do not live in an area with active Zika virus transmission, who are first evaluated 2–12 weeks after their last possible exposure should first receive a Zika virus IgM antibody test; if the IgM antibody test result is positive or equivocal, serum and urine rRT-PCR should be performed. Asymptomatic pregnant women with ongoing risk for exposure to Zika virus should receive Zika virus IgM antibody testing as part of routine obstetric care during the first and second trimesters; immediate rRT-PCR testing should be performed when IgM antibody test results are positive or equivocal. This guidance also provides updated recommendations for the clinical management of pregnant women with confirmed or possible Zika virus infection. These recommendations will be updated when additional data become available.

Introduction

Zika virus continues to spread worldwide, and as of July 21, 2016, 50 countries and territories reported active Zika virus transmission (locations with mosquitoes transmitting Zika virus to persons in the area). Although most persons with Zika virus infection are asymptomatic or have mild clinical disease, infection during pregnancy can cause congenital microcephaly and other brain defects.[1] Zika virus has also been linked to other adverse pregnancy outcomes, including miscarriage and stillbirth.[1,2] The U.S. Zika Pregnancy Registry (USZPR)** and the Puerto Rico Zika Active Pregnancy Surveillance System (ZAPPS)†† were established in collaboration with state, tribal, local, and territorial health departments to monitor pregnant women with confirmed or possible Zika virus infection to determine the risk for Zika virus infection during pregnancy and the spectrum of conditions associated with congenital Zika virus infection.[3] As of July 14, 2016, a total of 400 women in the 50 U.S. states and the District of Columbia, and 378 women in all U.S. territories (aggregated territories’ data from the USZPR and ZAPSS) were determined to have laboratory evidence of confirmed or possible Zika virus infection during pregnancy.§§

Data from the USZPR and published case reports indicate that Zika virus RNA can persist in serum of some pregnant women longer than had been previously reported; the longest documented duration of Zika virus RNA detection in serum is 10 weeks after symptom onset.[4–7] In addition, recent data indicate that Zika virus RNA might be detected in the serum or urine of some asymptomatic pregnant women.[7] The frequency of this finding is unknown, but the detection of Zika virus RNA in serum or urine provides a definitive diagnosis of Zika virus infection. Preliminary data suggest that plaque reduction neutralization testing (PRNT) might not discriminate between Zika virus and other flavivirus infections, particularly in persons with previous flavivirus exposure,[8] which complicates interpretation of serologic testing (IgM antibody test and PRNT). Given these challenges, expanded rRT-PCR testing might provide a definitive diagnosis for more pregnant women who are infected with Zika virus.

CDC has revised its interim guidance for U.S. health care providers caring for pregnant women with possible Zika virus exposure. The revised testing recommendations extend the timeframe for rRT-PCR testing of serum and include rRT-PCR testing for some asymptomatic pregnant women. CDC continues to evaluate all available evidence and will update recommendations as new information becomes available.

* Sex is specifically defined as vaginal sex (penis-to-vagina sex), anal sex (penis-to-anus sex), oral sex (mouth-to-penis sex or mouth-to-vagina sex), and the sharing of sex toys.

Barrier methods include male or female condoms for vaginal or anal sex, male condoms for oral sex (mouth-to-penis), and male condoms cut to create a flat barrier or dental dams for oral sex (mouth-to-vagina).

§Zika virus disease is defined as having at least one of the following signs or symptoms: acute onset of fever, rash, arthralgia, conjunctivitis, and laboratory confirmation of Zika virus infection.

https://www.cdc.gov/zika/geo/active-countries.html.

†† https://www.cdc.gov/zika/public-health-partners/zapss.html.

**https://www.cdc.gov/zika/hc-providers/registry.html.

§§ https://www.cdc.gov/zika/geo/pregwomen-uscases.html.

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