Evaluation of Patients for Zika Virus Infection in a Travel Clinic in the Southeast United States, 2016

Javier Valle, MD, MPH; Stephanie M. Eick, MPH; Jessica K. Fairley, MD, MPH; Jesse J. Waggoner, MD; Richard A. Goodman, MD, MPH; Eli Rosenberg, PhD; Henry M. Wu, MD


South Med J. 2019;112(1):45-51. 

In This Article

Abstract and Introduction


Objectives: Zika virus is an emerging infection that has posed vexing challenges to the US public health system. Improved characterization of patients with possible and confirmed infection is needed to better understand risks for infection in US travelers and to inform evolving evaluation guidelines.

Methods: We performed a retrospective electronic health record review of patients evaluated for Zika virus infection at an academic travel clinic in Atlanta, Georgia, from January 1 through August 31, 2016. We evaluated 46 patients who presented to the clinic during this period for evaluation of possible Zika virus infection, including patients with Zika virus symptoms, asymptomatic patients with possible exposure to Zika virus, and referral visits for Zika virus testing.

Results: Among the 46 patients evaluated, 30 (65.2%) were tested for Zika virus, 8 of whom (17.4%) had laboratory evidence of infection (7 confirmed, 1 probable). Cases, including confirmed and probable infections, most commonly had fever, rash, conjunctivitis, headache, and myalgia, although differences compared with noncases were not statistically significant. Many patients evaluated were not tested because of stringent testing criteria.

Conclusions: Our findings may help inform improvements in timely clinical decision making for Zika virus testing. This may assist clinicians and public health agencies. Wider access to accurate screening modalities will help providers evaluate and advise patients.


Zika virus, a mosquito-borne flavivirus, is an emerging virus that has challenged the US public health system. Following its emergence in the Western Hemisphere in 2015, there was increased concern regarding travel-related Zika cases diagnosed in nonepidemic countries.[1–3] During the height of the epidemic, the majority of US travelers who sought consultations before traveling to Zika-affected areas in the Western Hemisphere were of reproductive age and planned to travel for vacation.[4] In 2016, travel-related cases accounted for nearly all of the probable and confirmed cases that had been reported to ArboNET, the national surveillance system for arboviral infections of the Centers for Disease Control and Prevention (CDC).[5]

Most Zika virus infections are believed to be asymptomatic or mild.[6] Symptomatic patients commonly present with fever, rash, arthralgia, headache, conjunctivitis, and myalgia.[3] Less common manifestations of Zika virus infection include oral ulcers, abdominal pain, diarrhea, and neurologic syndromes such as Guillain-Barré.[7] Although the illness is typically mild, infection in pregnant women has been linked to congenital microcephaly and other complications of pregnancy.[8] Sexual transmission of Zika virus also is of public health concern, especially in nonendemic areas where non travelers may be exposed through their traveling partners.[9]

The CDC recommends that healthcare providers consult with their state health departments for guidance on ordering and interpreting Zika virus tests.[10] The Council of State and Territorial Epidemiologists (CSTE) clinical criteria for the case definition of Zika virus–compatible illness includes having at least one of the following symptoms: maculopapular rash, fever, conjunctivitis, or arthralgia. Cases also need to have epidemiologic linkage, such as travel history to a Zika virus–affected area.[11] The typical incubation period for Zika virus exposure from the bite of an infected Aedes mosquito and symptom onset is approximately 3 to 12 days.[12]

Response challenges for the US public health system—including initial limitations to testing resources, the size and characteristics of the at-risk patient population, and evolving recommendations for testing—impel improved characterization of patients with Zika virus infection to assist in better understanding the risks for travelers and to inform evolving evaluation guidelines. To assist in addressing this need, we analyzed a series of returned travelers presenting to an academic travel clinic with possible Zika virus infection.