Rapid spread of an ongoing outbreak of Zika virus disease in pregnant women in a Mexican hospital

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brazjinfectdis2017;21(5):554–556

w w w . e l s e v ie r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Brief

communication

Rapid

spread

of

an

ongoing

outbreak

of

Zika

virus

disease

in

pregnant

women

in

a

Mexican

hospital

Elvira

Garza-González

∗

,

Soraya

Mendoza-Olazarán,

Raúl

Roman-Campos,

Ricardo

Téllez-Marroquín,

Donato

Saldívar-Rodríguez,

Juan

A. Soria-López,

Abel

Guzman,

Samantha

Flores-Trevi ˜no,

Adrián

Camacho-Ortiz

UniversidadAutónomadeNuevoLeón,HospitalUniversitarioDr.JoséEleuterioGonzález,Monterrey,Mexico

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Articlehistory:

Received18December2016 Accepted7April2017 Availableonline22June2017

Keywords:

Zikavirusdisease

CongenitalZikavirussyndrome Microcephaly

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IntheﬁrstnineweeksofimplementationofaZikaVirusPreparednessPlaninaMexican PublicHospital,wecaredfor221pregnantwomenwithanysignalorsymptomsuggesting Zikavirusinfectionand99(44.8%)patientswerefoundtobepositiveforZikavirus.

Themedian ageofpatients was25.3years(range13–49). Symptoms inPCR-positive patientswererash(91.4%)followedbyheadache(53.1%),myalgia(46.9%),arthralgia(45.7%), pruritus(35.8%),retroocularpain(29.6%),conjunctivitis(21%),andfever(21%).Thewomen’s epidemiologicexposurehistoryindicateslocaltransmissionandacommunityoutbreak.

Zikavirus(ZIKV),avector-borneﬂavivirus,isresponsiblefor adengue-likeillness.Althoughmanyinfectionsare asymp-tomatic,amongthosewithsymptoms,fever,rash,jointpain, arecharacteristicallyobserved.In2013,aZIKVoutbreakwas reportedin FrenchPolynesia with19,000cases estimated.1

Twoyearslater,localtransmissionofZIKVwasdocumented inBrazil,withasuspectednumberofcasesofZIKVassociated diseaseof1,300,000byDecember2015.1,2

StudiesfromBrazilhaveprovidedgrowingevidenceofan associationbetweenZIKVinfectioninpregnantwomenand the developmentofsevere neural developmental disorders suchasmicrocephalyinfetusesand newborns.3 _Newborns

with microcephaly may develop hearing loss, motor skills

∗ _{Corresponding}_author.

E-mailaddress:elviragarzagzz@yahoo.com(E.Garza-González).

defects,intellectualdisability,developmentaldelay,andvision problems.4

ZIKVisprimarilytransmittedbymosquitoes;however, sex-ualandperinataltransmissionalsohavebeendemonstrated.5

InMexico,theﬁrstautochthonousZikavirusdisease(ZVD) casewasreportedinNovemberof2015andoccurredina res-identofMonterrey.6,7

From that time and until mid-July 2016, the National SurveillanceSystemcountremainedatﬁveZVDcasesforour entirestate,andthenbeganaslowrisethatacceleratedatthe beginningofSeptember.8

Herein wereporttheﬁrsteightweeksofsurveillanceof ZIKVinfectionamongpregnantwomeninathird-level teach-inghospitalinMonterrey,Mexico.

ThisisateachingpublichospitalinMonterrey,NuevoLeon thatservesthepopulationofMonterreymetropolitanareaand surroundingsstates.Thehospitalhas500beds,andon aver-agehas22,000hospitalizationand 9000deliveriesannually. http://dx.doi.org/10.1016/j.bjid.2017.04.008

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Fig.1–DistributionofZikacasesthroughthefourweeksintheMetropolitanareaofMonterreyNuevoLeon,Mexico.

Severalintra-institutional meetingsbetween thelaboratory and clinical (infectious diseases and gynecology-obstetrics) servicesleadtoajointlydevelopedZVDPreparednessPlan.

TheZVDPlandetailstheclinicalandtheepidemiologicrisk assessmenttobeusedforanypregnantwomanpresenting forcarewithanysignalorsymptomsuggestingZIKV infec-tion(rash,headache,myalgia,arthralgia,pruritus,retroocular pain,conjunctivitis,or/andfever)and directstheclinicians to obtain blood and urine clinical samples for diagnostic testing.9 _The_ZVD _Plan _was_presented_at_our _{hospital-wide}

grandroundsonSeptember13,2016,andthesurveillanceof ZIKVinfectioninpregnantwomenbeganwithnoreportsof untilSeptember25.From SundayeveningSeptember 25 to September26,ninepregnantandunrelatedwomenpresented toouremergencyroom(ER)withanysignalorsymptom sug-gestingZIKVinfection.During theremainder ofthatweek, anduptoSaturday,November25,anadditional212women presentedforcaretotheERwithanysignalorsymptom sug-gestingZIKVinfection.Themedianageofpatientswas25.33 years(range13–49).

In the initial 9-week period of simultaneous diagnos-tictesting forthe three arboviruses (dengue virus (DENV), chikungunyavirus(CHIKV),andZIKV),weprocessedsamples belongingto221patients(7singleserums,3singleurines,and 422pairedserumandurinesamples).ViralRNAwasextracted fromtheserumsamplesbyusingtheQIAampViralRNAMini Kit(QIAGEN,Hilden,Germany).RNAwasreversetranscribed byusingtheSuperscriptIIIPlatinumOneStepRealTime RT-PCRsystem(Invitrogen,Carlsbad,CA,USA)andsubjectedto PCRsspeciﬁcforDENV,CHIKV,andZIKVusingtheCDC Trio-plexReal-timeRT-PCRAssay.10

Ofthe221pregnantpatientstestedbyTrioplexRT-PCR,one patientwaspositiveforCHIKV(andnotforDENVorZIKV); threepatientswerepositiveforDENV(andnotforCHIKVor ZIKV)and99(44.8%)patientswere positiveforZIKV. Symp-tomsinPCR-positivepatientswererash(91.4%)followedby headache (53.1%),myalgia (46.9%), arthralgia(45.7%), pruri-tus(35.8%),retroocularpain(29.6%),conjunctivitis(21%),fever (21%), and diarrhea(2.5%). The gestationalages ofthe 221 pregnanciesrangedfrom4.5to41.5weeks(8.3%intheﬁrst and20.4%inthesecondtrimester).Allhadahigh-resolution ultrasonographic(HRUS)evaluationandnocranial abnormali-tiesorotherabnormalﬁndingsinthefetuses,ortheplacentas weredetectedinthisbaselineassessment.Twowomenwith conditions deemed to be unrelatedto ZVD (one at riskof pretermlabor,onewithaUTI)werehospitalizedandresolved satisfactorily;allothersweredischargedhomefromthe diag-nosticERvisit.

AllthewomenareresidentsoftheMonterrey metropoli-tan area (Fig. 1). None reported a travel history consistent withZIKVtransmissionoccurringsomewherebesidestheir placeofresidency.SeventyRT-PCRpositivepatientsprovided informationaboutlocalexposure:37(52.9%)hadcommunity contactswithsimilarfebrilerashillness,18(25.7%)hadboth communityandintradomiciliaryillcontacts,and4(5.7%)had in-housecontacts.Amongthe118RT-PCR-negativepatients with probable ZVD, the mostcommon symptom was rash (81.3%),and78.4%reportedcommunityillcontacts.

WecomposedtheZVDPlanexpectingtoactivateit grad-ually; but instead,we quicklyfacedanepidemic. OurZVD PreparednessPlanfurtherincludes(a)monthlyobstetricHRUS forpossiblecongenitalﬁndings,(b)ZIKVRNAtestingofbabies

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and mothers, and (c) monitoring the childrenby the neu-ropediatricspecialists.Todate,sixwomenhavedelivereda healthyliveinfant,withnoevidenceofneurologicaldamage innewborns.Maternalandinfantbloodandurinesalltested PCR-negativeforZIKV.

Our health facility is a teaching hospital in Monterrey, NuevoLeonState,Mexico.NuevoLeonisnorthernlandlocked MexicoState,andourenvironmentalconditionspermitthe existenceoftheAedesvectorthattransmitsDengue, Chikun-gunyaandZika.TheunpredictedswiftnessofZIKVspreadthat causedourActionPlantobeputintoimplementationmodeat topspeed,torespondtowhatappearstobeaverylarge out-breakoccurringwhichisstilloccurringinourcityandamong thepopulationthatusesourhospitalfortheirprimaryhealth careneeds,includingprenatalandobstetriccare.Wewantto documentthelessonslearnedandchallengesfacedandshare themwithotherinstitutionsfacingthesameproblem.

Thisreportdescribestherapidspreadofanongoing out-breakofZVDaffectingthepregnantwomencaredforatour hospital,andtheinvolvednessofmanaginganinstitutional responsetoahealthcrisis.

Conﬂicts

of

interest

Theauthorsdeclarenoconﬂictsofinterest.

Acknowledgments

WethankMr.GregorioBustosforhistechnicalassistanceand tothe U.S. Centers forDisease Control and Prevention for providingourlaboratorywiththeTrioplexReal-timeRT-PCR Assay.

Thispublicationwasmadepossiblethroughsupport pro-vided by the Bureau for Global Health, U.S. Agency for InternationalDevelopment,underthetermsofanInteragency AgreementwiththeU.S.CentersforDiseaseControl(CDC).

Theopinionsexpressedhereinarethoseoftheauthor(s)and donotnecessarilyreﬂecttheviewsoftheU.S.Agencyfor Inter-nationalDevelopment.

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