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      Identify-Isolate-Inform: A Tool for Initial Detection and Management of Zika Virus Patients in the Emergency Department

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          Abstract

          First isolated in 1947 from a monkey in the Zika forest in Uganda, and from mosquitoes in the same forest the following year, Zika virus has gained international attention due to concerns for infection in pregnant women potentially causing fetal microcephaly. More than one million people have been infected since the appearance of the virus in Brazil in 2015. Approximately 80% of infected patients are asymptomatic. An association with microcephaly and other birth defects as well as Guillain-Barre Syndrome has led to a World Health Organization declaration of Zika virus as a Public Health Emergency of International Concern in February 2016. Zika virus is a vector-borne disease transmitted primarily by the Aedes aegypti mosquito. Male to female sexual transmission has been reported and there is potential for transmission via blood transfusions. After an incubation period of 2–7 days, symptomatic patients develop rapid onset fever, maculopapular rash, arthralgia, and conjunctivitis, often associated with headache and myalgias. Emergency department (ED) personnel must be prepared to address concerns from patients presenting with symptoms consistent with acute Zika virus infection, especially those who are pregnant or planning travel to Zika-endemic regions, as well as those women planning to become pregnant and their partners. The identify-isolate-inform (3I) tool, originally conceived for initial detection and management of Ebola virus disease patients in the ED, and later adjusted for measles and Middle East Respiratory Syndrome, can be adapted for real-time use for any emerging infectious disease. This paper reports a modification of the 3I tool for initial detection and management of patients under investigation for Zika virus. Following an assessment of epidemiologic risk, including travel to countries with mosquitoes that transmit Zika virus, patients are further investigated if clinically indicated. If after a rapid evaluation, Zika or other arthropod-borne diseases are the only concern, isolation (contact, droplet, airborne) is unnecessary. Zika is a reportable disease and thus appropriate health authorities must be notified. The modified 3I tool will facilitate rapid analysis and triggering of appropriate actions for patients presenting to the ED at risk for Zika.

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          Update: Interim Guidelines for Health Care Providers Caring for Pregnant Women and Women of Reproductive Age with Possible Zika Virus Exposure - United States, 2016.

          CDC has updated its interim guidelines for U.S. health care providers caring for pregnant women during a Zika virus outbreak (1). Updated guidelines include a new recommendation to offer serologic testing to asymptomatic pregnant women (women who do not report clinical illness consistent with Zika virus disease) who have traveled to areas with ongoing Zika virus transmission. Testing can be offered 2-12 weeks after pregnant women return from travel. This update also expands guidance to women who reside in areas with ongoing Zika virus transmission, and includes recommendations for screening, testing, and management of pregnant women and recommendations for counseling women of reproductive age (15-44 years). Pregnant women who reside in areas with ongoing Zika virus transmission have an ongoing risk for infection throughout their pregnancy. For pregnant women with clinical illness consistent with Zika virus disease,* testing is recommended during the first week of illness. For asymptomatic pregnant women residing in areas with ongoing Zika virus transmission, testing is recommended at the initiation of prenatal care with follow-up testing mid-second trimester. Local health officials should determine when to implement testing of asymptomatic pregnant women based on information about levels of Zika virus transmission and laboratory capacity. Health care providers should discuss reproductive life plans, including pregnancy intention and timing, with women of reproductive age in the context of the potential risks associated with Zika virus infection.
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            Identify-Isolate-Inform: A Modified Tool for Initial Detection and Management of Middle East Respiratory Syndrome Patients in the Emergency Department

            Middle East respiratory syndrome (MERS) is a novel infectious disease caused by a coronavirus (MERS-CoV) first reported in Saudi Arabia in September 2012. MERS later spread to other countries in the Arabian Peninsula, followed by an outbreak in South Korea in 2015. At least 26 countries have reported MERS cases, and these numbers may increase over time. Due to international travel opportunities, all countries are at risk of imported cases of MERS, even if outbreaks do not spread globally. Therefore, it is essential for emergency department (ED) personnel to be able to rapidly assess MERS risk and take immediate actions if indicated. The Identify-Isolate-Inform (3I) tool, originally conceived for initial detection and management of Ebola virus disease patients in the ED and later adjusted for measles, can be adapted for real-time use for any emerging infectious disease. This paper reports a modification of the 3I tool for use in initial detection and management of patients under investigation for MERS. Following an assessment of epidemiologic risk factors, including travel to countries with current MERS transmission and contact with patients with confirmed MERS within 14 days, patients are risk stratified by type of exposure coupled with symptoms of fever and respiratory illness. If criteria are met, patients must be immediately placed into airborne infection isolation (or a private room until this type of isolation is available) and the emergency practitioner must alert the hospital infection prevention and control team and the local public health department. The 3I tool will facilitate rapid categorization and triggering of appropriate time-sensitive actions for patients presenting to the ED at risk for MERS.
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              WHO STATEMENT ON THE FIRST MEETING OF THE INTERNATIONAL HEALTH REGULATIONS (2005) (IHR 2005) EMERGENCY COMMITTEE ON ZIKA VIRUS AND OBSERVED INCREASE IN NEUROLOGICAL DISORDERS AND NEONATAL MALFORMATIONS

              (2016)
              1 February 2016 ¦ GENEVA - The first meeting of the Emergency Committee (EC) convened by the Director-General under the International Health Regulations (2005) (IHR 2005) regarding clusters of microcephaly cases and other neurological disorders in some areas affected by Zika virus was held by teleconference on 1 February 2016, from 13:10 to 16:55 Central European Time. The WHO Secretariat briefed the Committee on the clusters of microcephaly and Guillain-Barré Syndrome (GBS) that have been temporally associated with Zika virus transmission in some settings. The Committee was provided with additional data on the current understanding of the history of Zika virus, its spread, clinical presentation and epidemiology. The following States Parties provided information on a potential association between microcephaly and other neurological disorders with Zika virus: Brazil, France, United States of America, and El Salvador. The Committee advised that the recent cluster of microcephaly cases and other neurological disorders reported in Brazil, following a similar cluster in French Polynesia in 2014, constitutes a Public Health Emergency of International Concern (PHEIC). The Committee provided the following advice to the Director-General for her consideration to address the PHEIC (clusters of microcephaly and other neurological disorders) and their possible association with Zika virus, in accordance with IHR (2005). Microcephaly and other neurological disorders Surveillance for microcephaly and GBS should be standardized and enhanced, particularly in areas of known Zika virus transmission and areas at risk of such transmission. Research into the etiology of new clusters of microcephaly and other neurological disorders should be intensified to determine whether there is a causative link to Zika virus and/or other factors or co-factors. As these clusters have occurred in areas newly infected with Zika virus, and in keeping with good public health practice and the absence of another explanation for these clusters, the Committee highlights the importance of aggressive measures to reduce infection with Zika virus, particularly among pregnant women and women of childbearing age. As a precautionary measure, the Committee made the following additional recommendations: Zika virus transmission Surveillance for Zika virus infection should be enhanced, with the dissemination of standard case definitions and diagnostics to at-risk areas. The development of new diagnostics for Zika virus infection should be prioritized to facilitate surveillance and control measures. Risk communications should be enhanced in countries with Zika virus transmission to address population concerns, enhance community engagement, improve reporting, and ensure application of vector control and personal protective measures. Vector control measures and appropriate personal protective measures should be aggressively promoted and implemented to reduce the risk of exposure to Zika virus. Attention should be given to ensuring women of childbearing age and particularly pregnant women have the necessary information and materials to reduce risk of exposure. Pregnant women who have been exposed to Zika virus should be counselled and followed for birth outcomes based on the best available information and national practice and policies. Longer-term measures Appropriate research and development efforts should be intensified for Zika virus vaccines, therapeutics and diagnostics. In areas of known Zika virus transmission health services should be prepared for potential increases in neurological syndromes and/or congenital malformations. Travel measures There should be no restrictions on travel or trade with countries, areas and/or territories with Zika virus transmission. Travellers to areas with Zika virus transmission should be provided with up to date advice on potential risks and appropriate measures to reduce the possibility of exposure to mosquito bites. Standard WHO recommendations regarding disinsection of aircraft and airports should be implemented. Data sharing National authorities should ensure the rapid and timely reporting and sharing of information of public health importance relevant to this PHEIC. Clinical, virologic and epidemiologic data related to the increased rates of microcephaly and/or GBS, and Zika virus transmission, should be rapidly shared with WHO to facilitate international understanding of the these events, to guide international support for control efforts, and to prioritize further research and product development. Based on this advice the Director-General declared a Public Health Emergency of International Concern (PHEIC) on 1 February 2016. The Director-General endorsed the Committee’s advice and issued them as Temporary Recommendations under IHR (2005). The Director-General thanked the Committee Members and Advisors for their advice. Available from: http://www.who.int/mediacentre/news/statements/2016/1st-emergency-committee-zika/en/
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                Author and article information

                Journal
                West J Emerg Med
                West J Emerg Med
                WestJEM
                Western Journal of Emergency Medicine
                Department of Emergency Medicine, University of California, Irvine School of Medicine
                1936-900X
                1936-9018
                May 2016
                04 April 2016
                : 17
                : 3
                : 238-244
                Affiliations
                [* ]University of California Irvine Medical Center, Department of Emergency Medicine, Center for Disaster Medical Sciences, Orange, California
                []University of California Irvine Medical Center, Department of Emergency Medicine and Department of Medicine, Division of Infectious Diseases, Orange, California
                []Qassim University, Department of Emergency Medicine, Saudi Arabia
                Author notes
                Address for Correspondence: Kristi L. Koenig, MD, University of California Irvine, Department of Emergency Medicine, Center for Disaster Medical Sciences, 333 The City Boulevard West, Suite 640, Rt 128-01, Orange, CA, 92868. Email: kkoenig@ 123456uci.edu .
                Article
                wjem-17-238
                10.5811/westjem.2016.3.30188
                4899052
                27330653
                c963c5fe-0c89-4912-8cd9-3c7e76a9b676
                © 2016 Koenig et al.

                This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http://creativecommons.org/licenses/by/4.0/

                History
                : 24 February 2016
                : 21 March 2016
                Categories
                Endemic Infections
                Concept Paper

                Emergency medicine & Trauma
                Emergency medicine & Trauma

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