Zika in the ED: How Emergency Care Staff can Take Action

Moderator: Ashley Ghaffarzadeh

Presenters: Jon Mark Hirshon, MD, PhD, MPH; Monica Escalante Kolbuk, MSN, RN, CEN

Date/Time: November 1, 2016, 2:00 - 3:00 pm ET

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Coordinator: Welcome and thank you for standing by. At this time all participants are in a listen-only mode. During the question and answer session please press star 1. Today's conference is being recorded. If you have any objections you may disconnect at this time.

Now I would like to turn the meeting over to Ashley Ghaffarzadeh. Thank you. You may begin.

Ashley Ghaffarzadeh: Thank you Diane. Good afternoon, I'm Ashley Ghaffarzadeh and I'm representing the Clinician Outreach and Communication Activity, COCA, with the Emergency Risk Communications Branch at the Centers for Disease Control and Prevention.

I am delighted to welcome you to today's COCA call, "Zika in the ED: How Emergency Care Staff Can Take Action".

You may participate in today's presentation by audio only, via Webinar, or you may download the slides if you are unable to access the Webinar. The PowerPoint slide set and the Webinar link can be found on our COCA Web page at emergency.cdc.gov/coca.

For continuing education - I'm sorry. Free continuing education is offered for this COCA call. Instruction on how to earn continuing education will be provided at the end of the call.

CDC, our planners, presenters, and their spouses' partners wish to disclose they have no financial interest or other relationships with manufacturers of commercial products, suppliers of commercial services, or commercial supporters, with the exception of Dr. Jon Mark Hirshon. He is a consultant for Pfizer related to sickle cell disease.

Planners have reviewed content to ensure there is no bias. This presentation will not include any discussion of the unlabeled use of a product or products under investigational use.

At the end of the presentation you will have the opportunity to ask presenters questions. On the phone dialing star 1 will put you in the queue for questions. You may submit questions through the Webinar system at any time during this presentation by selecting the Q&A tab at the top of the Webinar screen and typing in your question.

Questions are limited to clinicians who would like information related to Zika virus infection. For those who have media questions, please contact CDC Media Relations at 404-639-3286 or send an email to media@cdc.gov. If you are a patient, please refer your questions to your healthcare provider.

At the conclusion of today's session, the participant will be able to: outline the importance of screening protocols for Zika; review nursing assessment and clinical interventions as it relates to Zika; describe the process for reporting Zika cases; discuss patient education and discharge teaching for any people who may be at risk for, exposed to, or diagnosed with Zika.

At this time I would like to introduce our speakers. First, Dr. Satish Pillai will provide welcoming remarks.

Commander Satish Krishna Pillai is the Deputy Incident Manager for CDC's Zika Response since May 2016 where he helped oversee and coordinate a variety of epidemiologic, entomologic, and laboratory activities across the CDC Zika response.

Dr. Pillai is an internal medicine and infectious disease expert who joined the CDC as an Epidemic Intelligence Service Officer in 2011. Following his tour as an EIS officer he joined the Division of Preparedness and Emerging Infection in CDC's National Center for Emerging and Zoonotic Infectious Disease.

As a Deputy Team Lead for the July 2014 Liberia Ebola Response Team, Commander Pillai helped develop the original Incident Management System for the Liberian Ministry of Health.

He also was a course developer and instructor at FEMA's Center for Domestic Preparedness in Anniston, Alabama where healthcare workers were trained in lifesaving personal protection and infection control before deploying to Ebola's treatment unit in West Africa.

In February and March of this year he was the final Incident Manager for CDC Ebola Response, shepherding the agency's transition from the Ebola Emergency Response to supporting the three West African countries affected by Ebola to better prepare for future disease outbreaks.

Out first presenter is Dr. Jon Mark Hirshon. He is a professor in the Department of Emergency Medicine and in the Department of Epidemiology and Public Health at The University of Maryland School of Medicine.

He is Board Certified in both Emergency Medicine and Preventive Medicine and has a Doctor Degree in Epidemiology and is also a member of The American College of Emergency Physicians Epidemic Experts Panel.

Additionally, he co-authored a publication entitled, Zika Virus: Clinical Information for Emergency Providers.

Our second presenter is Nurse Monica Escalante Kolbuk. She is Senior Associate for the Institute of Quality, Safety, and Injury Prevention, Emergency Nurse's Association, and has practiced emergency nursing for over a decade.

She began her education at DePaul University Chicago where she received her Bachelor's Degree in Political Science. Her interest in health politics influenced her decision to pursue nursing, achieving her Masters in Nursing with an emphasis in Public Health.

Her work at ENA focuses on developing clinical resources to support various topics and issues of importance to emergency nurses. She is also a member of the American College of Emergency Physicians, ACEP, Epidemic Expert Panel, and has worked collaboratively with CDC and ACEP on previous practice resources such as: to identify, isolate, inform emergency department evaluation and management for patients who present with possible Ebola virus disease triage algorithm.

She has also worked with Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality to develop Ebola training module for nurses, physicians, and healthcare workers.

She continues to work as an emergency nurse using an evidence-based approach to refining practice.

At this time please welcome Dr. Pillai.

Satish Pallai: Thank you Ashley. Good afternoon. CDC's Zika Emergency Activation is complex. And nearly every part of the agency is supporting the response. Our number one priority is protecting pregnant women who, if infected during pregnancy, can pass Zika to their developing fetus.

Zika virus infection during pregnancy is a cause of the devastating neurologic birth defect microcephaly, as well as other severe birth defects.

Our emergency response has brought together CDC scientists with expertise in arboviruses like Zika, reproductive health, birth defects and developmental disabilities, diagnostic testing, mosquito control, and traveler's health.

These experts help monitor and report cases of Zika to help improve our understanding of how Zika is spreading and where it's spreading; provide guidance to travelers and Americans living in areas with current outbreaks;

develop laboratory tests to diagnose Zika; provide technical assistance to states to help prepare and respond to Zika, including technical experts who understand methods used to control mosquitos that can transmit Zika.

We are conducting studies to learn more about the link between Zika and microcephaly, and Zika and Guillain-Barré Syndrome.

And we've deployed CDC Emergency Response Teams or CERTs that include experts in Zika virus pregnancy and birth defects, mosquito control, diagnostic testing, and risk communications to jurisdictions that have requested additional assistance in addressing the Zika outbreak.

We learn more about Zika every day. For the latest guidance I'd encourage you to visit cdc.gov/Zika and consult the "What's New" section which also has a timeline indexing all of our Zika related guidance and alerts.

As clinicians, we all have an important role to play in helping inform the public about Zika and ensuring the health and safety of pregnant women and their babies.

Given the significant interface that emergency department providers have with their communities, and the breadth and volume of clinical care you provide, we value the opportunity to partner with the emergency medicine community in disseminating information regarding Zika and further strengthening collaborations between public health and clinical communities.

As noted by Ashley, we have two speaker from the emergency department community today, Dr. Jon Mark Hirshon and Ms. Monica Kolbuk.

At this point, I would like to thank you again for participating and will turn the line over to Dr. Hirshon. Thank you very much.

Jon Mark Hirshon: Thank you Dr. Pillai. I appreciate this opportunity to discuss the important topic of Zika with my colleagues and, I'm going to go ahead and get started on this.

It's important from, you know, an overall perspective to understand that there are many mosquito-borne viruses. And some are more deadly and concerning than others.

Today we're going to focus on Zika. Zika is a virus that has really dramatically come to our attention over the past year, though it was initially identified in the 40s.

However before we get too focused on Zika specifically, let's make sure we've got our terms correct.

So when we talk about an arbovirus, that's an arthropod-borne virus such as - and arthropods are mosquitos, ticks, and sandflies.

So it's really - when we say arbovirus, it's a mechanism of transmission we're looking at. And there are a number of different arbovirus families, though the one that we're looking at most is the Flavivirus family, which are single stranded RNA viruses.

Arboviruses, as said, are transmitted by arthropods. In this instance we're talking about, mosquito-borne. And though they can have rare person-to-person transmission -- such as from blood-borne, so, transfusion or sharing of needles, organ transplantation, breastfeeding, intrauterine, and sexual transmission. And we've seen many of these transmission patterns occur with Zika.

And of the major arbovirus viral families, the one that we're looking at really at this point is the Flavivirus family, which includes Dengue, West Nile, Yellow Fever, and Zika.

So you can see that this is a major family when it comes to diseases among men and women.

So let's talk a little bit about Zika virus specifically. So as I said, it's a Flavivirus. It's mosquito-borne, and the two main vectors that we see are the Aedes aegypti and the Aedes albopictus.

And again, Aedes aegypti is probably the main one that we know of. But we know that it is transmissible by both of these.

Its primary amplifying host - so the main host that you see it kind of grow in- are humans and primates.

Its distribution is primarily tropical around the world. Mostly in Africa is where it started, but we see it now a great deal in South and Central America, as well as in parts of the Pacific.

In the U.S. - in the Continental U.S. currently it's only seen in a small area around Miami, Florida, so down in Florida. Though if you look at other places, such as Puerto Rico, there's a huge amount of Zika virus going on there.

However, unfortunately, if you take a look at something like the history of West Nile virus, the likelihood of spread of Zika throughout the U.S., despite best efforts, is there and something that we need to be aware of and something the CDC is actively trying to prevent.

Unfortunately, there is no vaccine for Zika at this time, though vaccines are - there are efforts to develop vaccines.

Of the four major viruses I mentioned previously, Zika, West Nile, Dengue, and Yellow Fever, there is a Yellow Fever virus [vaccine]. So there's some hope that over time we'll be able to get a Zika virus. But at this point there is not one.

And essentially you treat Zika symptomatically. So for individuals who have the disease it's mostly a symptomatic treatment.

So who's at risk? Folks that are at risk as I said, are folks that go to Central and South America, including the Caribbean; some parts of Oceania and the Pacific Islands.

Now we could list a long list of countries and regions. My recommendation is that if you're thinking of traveling to one of these areas, go to the CDC Web site. They keep an updated list in terms of being able to know where the active countries are for Zika virus.

As I said previously, Puerto Rico right now is very active, and there are some localized areas around Miami.

So those are for in terms of travelers. Now for other people, if you've got a partner that's been infected with Zika or has potentially traveled to one of these areas, then you're at risk for transmission from - primarily from sexual contact - unprotected sexual contact.

So those are the individuals at risk. What does Zika look like as a clinical disease? Well for the vast majority, you know, probably 80%, most individuals with Zika are asymptomatic. They don't have anything or they have a very mild infection.

If they do have something which are a maculopapular rash, usually pruritic, low grade or fever around 38.5, aches, you know, myalgia, arthralgia, they'll have a non-purulent conjunctivitis, they'll have a little bit of conjunctival hyperemia; a little red eye, headache, achy all over. Maybe a little swelling around the joints. So it's really very much a mild type of symptom -- symptomology.

Now there are folks that will get serious complications. They're relatively rare; so they can get Guillain-Barré. And if you see someone with Guillain-Barré then you're going to treat them for Guillain-Barré. There's not anything different simply because they're Zika or not Zika.

And as mentioned earlier, the individuals who are really at risk are the - are congenital infections. So pregnant women infected with Zika are at risk for - their infants are at risk - for serious congenital malformations such as microcephaly. And there are other pregnancy-related complications as well, such as miscarriage.

But from an emergency department perspective, this is really not the area that we're going to be, in general, be treating. You're going to come in and treat the patient for what they have. If mild and viral infections; if they're having a miscarriage, you treat them for what they're presenting with.

So from a clinical perspective, at least in acute settings, there's not much we're going to do.

How do you diagnose Zika? You diagnose it primarily based on travel history and symptoms. There is testing for Zika. And I'll show in a second the slide for testing for someone who's pregnant with potential Zika. But the answer is, it's a complicated process.

There are no currently approved commercial tests available. There are some tests that the FDA has authorized for use under an emergency use authorization.

What I would recommend is that again, you visit the CDC Web site to understand what the most updated Zika testing recommendations are.

And here, so you know, if you have someone who comes in who's pregnant, as you can see it's a complicated testing algorithm. In part because there's a lot of cross-reactivity for some of these tests with other Flavivirus.

So is it Dengue or is it Zika? So depending on the type of testing you have and what's available to you, again check the CDC Web site for current updates. Communicate with your hospital Infection Control individual so you understand what they expectations are at your institution.

And make sure that there's a communication between your department and the local health department to understand, if you're going to test someone, where you send the specimen and how they're going to be processed; those types of questions.

Again, this is - while there's some general guidelines and the CDC has some specific guidelines for testing for pregnant women, it really is going to be a local effort, depending on where you are, the symptomatology; the person's past travel history. So again, this is going to have to be tailored to your individual department.

And what is the treatment? Well right now the treatment is rest, fluids, and acetaminophen. You don't - you want to stay away, as with a lot of the other Flaviviruses, you really don't want to go towards aspirin or non-steroidal. So really, it's just symptomatic treatment.

Now what do you want to tell a concerned patient? In general you can reassure them that it's a mild disease, and that the vast majority of people are not going to get significant complications from the infection.

Tell them that if they travel that they're - look at their risk profile. If they haven't traveled or haven't been in contact with someone who has traveled to an endemic area with mosquitoes and Zika, then they're not likely to have it.

If they are having sex with someone who has traveled there, or they've traveled there and having sex with someone, then they need to be aware that they should take preventive measures. And we'll talk about those in a moment.

So in general, the vast majority of people it's going to be an issue of reassurance and symptomatic treatment.

Now if someone is pregnant and they're concerned about having gotten Zika, what do you tell them? And I would recommend that you send them to mothertobaby.org. This is a site that you can get through the CDC. And they have both English and Spanish individuals available to talk to people to give them advice and guidance. And potentially help them in terms of testing schema.

In the emergency department you're going to treat the acute patient. The key here is to be able to make sure that you got the appropriate mechanisms for screening, as Monica will tell you in a little bit. But also to make sure that you've got appropriate referral mechanisms available so that the individuals can get the care they need and the reassurances they potentially need as well.

So for a traveler going to an endemic area, it's really prevention against getting bitten.

So in general wear long pants, long shirt you know, long-sleeved shirt. Use appropriate mosquito repellents. Stay in places with screening or air condition if possible. And really the recommendation at this point is that pregnant women should not, or individuals who want to get pregnant should avoid travel to Zika endemic areas.

From a sexual partner perspective it's really, abstain from sex or use a barrier method for at least eight weeks after illness onset if a female partner is likely to have Zika. And the current recommendations are six months, the barrier method, or abstention after illness if a male partner is likely to have Zika.

And again, these are things that are - you know, there's a lot of active research in this area because we're still learning about Zika. So these recommendations may change as our knowledge and experience and the research related to Zika expands.

So kind of in conclusion of my part, Zika is not contagious in the way that Ebola was. It's not lethal but it appears to strike in an especially cruel way, depressing brain growth in babies born to infected mothers.

And like so many other pathogens that preceded it, the Zika virus has seemingly whirled out of nowhere, reinforcing how difficult it is to predict confidently, which ones will go rogue.

So the importance here is awareness, reassurance for patients, and appropriate follow up.

With that I'm going to say thank you for your attention. And in the emergency department you know, we work as a team. So it's my pleasure to introduce and to transition to my partner on this talk, Monica Escalante Kolbuk.

Monica Escalante Kolbuk: Thank you Dr. Hirshon and good afternoon everyone. I'm grateful for the opportunity to talk about a concern to all emergency care providers.

I want to first start by talking about screening. As an emergency nurse we do a lot of screening and we may not even know it. We do it so often it's almost second nature to us.

With Zika, identifying emergency care patients who are at risk for Zika is one of the first steps we can take to prevent further exposures. Recognizing potential patients and understanding the clinical presentations of Zika virus can really help us in early detection, as well as early response.

In order to detect potential patients who are both at risk for or might have been exposed to Zika virus, clinicians must be asking the right questions. And how do we do that?

Really we can do that by universally screening everyone that presents to the emergency care setting. In healthcare we use screening interventions to help us identify diseases early, enable early intervention and treatment in order to reduce the chance of disease and mortality.

Screening for Zika virus will help us to identify exposed patients early, allowing earlier intervention and treatment which in turn really assists in reducing the chance of further disease transmission.

Knowing earlier that someone is at risk for or might have been exposed to Zika virus enables healthcare providers to intervene earlier, begin testing and treatment soon, and helps clinicians target patient education and disease information that particular individual needs.

Also identifying Zika early through screening can help public health authorities track exposures, conduct follow-up, and determine eligibility for the U.S. Zika Pregnancy Registry.

So we're going to do a poll and I want to see if those of you who have access to the poll who are on the Webinar here, I want to know of those of you who are currently working in emergency department or an urgent care setting, are you currently screening all patients for Zika virus? So I'll give you about 15 seconds or so to go ahead and complete the poll.

Okay I'm going to close the poll. And then let's see what our results are. Okay, so that's about where I thought we would be at.

So looking at these numbers up here on the screen, it seems you know, about half of us are actually screening all patients for potential Zika virus.

All right, so when we talk about who should be screened for Zika virus, we have to remember that many people infected with Zika virus, who even have symptoms or only have mild symptoms, if that.

As Dr. Hirshon mentioned earlier, the most common symptoms of Zika are fever, rash, joint pain, and conjunctivitis. Because these symptoms are so similar to the common cold or flu or even other diseases, it's important to assess every patient for potential exposure to Zika virus that presents to an emergency care setting.

Most importantly, healthcare providers should be assessing all pregnant women for possible exposure, and evaluate for signs and symptoms of Zika virus disease at every clinical encounter.

Clinicians will find the updated Interim Pregnancy Guidance Testing algorithm that Dr. Hirshon talked about, located on the CDC's Web site which is very useful for this assessment.

While some may tend to only think about pregnant women being impacted, we have to remember that Zika can be passed through sexual contact even if the infected person does not have symptoms at the time or may not even know they are infected. Therefore screening for potential exposure is necessary for all individuals.

The first question asked by most triage nurses is, what brings you in today? It's a typical question. We ask it all the time. And whether its abdominal pain, finger injury, or say headache, travel history should be included in the primary assessment.

This can easily be done by starting with a very simple but important question - have you had any recent travel? Or has anyone close to you recently traveled?

But not all patients presenting to an emergency care setting are going to know what areas are impacted by Zika. This type of open-ended question, you know, have you had any recent travel, has anybody recently, close to you traveled? This type of open-ended question really puts the burden upon the clinician to know which areas are affected by Zika.

And as emergency nurses and emergency care providers we should also be prompting and asking our EMS providers, as we receive radio calls, to screen patients they bring to us at the emergency department.

Internal and external hospital Web sites should include a link to the CDC Zika Web site to ensure that all staff have easy access to the most up-to-date guidance including current areas affected and other training and clinical resources.

So because not all patients are going to know, these links and resources are really going to help you determine which areas are impacted and whether or not that patient needs to be further evaluated.

Having a map or something similar to this with tips for triage that is updated can help to remind clinicians to screen everybody. So this map, you can see up here is kind of triggering questions. Identify exposure history in patients at risk.

Now the map is rather general. As you can see, it's only pointing to the Americas, so you're going to want something more updated that shows Miami and Puerto Rico as well. So it's important to make sure that everyone has easy access to online resources.

At ENA we developed a quick fact sheet for emergency nurses with common questions and answers. We recommend that emergency departments post this or something similar, with quick information where it can be easily assessed as a reminder to screen all patients.

So, once we've assessed whether an individual has been exposed by asking travel and exposure history questions, then our next step is to identify the signs and symptoms which are listed here and which Dr. Hirshon mentioned.

After it is determined if there is a potential risk for Zika, then we're going to have to figure out what sort of isolation precautions are needed based on the symptoms.

For Zika virus, standard precautions should be implemented. Isolating or moving the patient in a private room would be an ideal situation, not only for their privacy but also to limit distractions so that appropriate patient education can be provided to the patient and their family.

A question that often presents is, as an ED nurse can I get Zika from my patient if they have it?

And what we have to remember is that body fluids, including blood, vaginal secretions and semen have been implicated in transmission of Zika virus. So it's really important for us to practice correct standard precaution.

Occupational exposure that requires evaluation includes percutaneous exposure like a needle stick, or other sharp injury, or exposure of any non-intact skin or mucus membrane with blood, body fluids, secretion and excretions of the suspected confirmed patient.

Before I jump over to the process for informing and reporting cases, I want to first talk a little bit about clinical interventions from a nursing perspective.

Dr. Hirshon mentioned a lot of these interventions that we would be doing, but it's important to be aware that people with Zika virus infection can be asymptomatic or mildly symptomatic. And therefore we should consider Zika virus disease in our differential diagnosis for patients with appropriate risk factors.

Since there are no antiviral treatments for Zika, we're going to really focus on supportive care. And that should be given for any symptoms such as you know, rest, anti-pyretic, pain management for any pain that they have, and possibly fluids.

Clinicians should not be administering aspirin or other non-steroidal anti-inflammatory drugs or anything until Dengue can be ruled out, to reduce the risk of bleeding, as Dr. Hirshon had mentioned.

Nursing intervention should also include a thorough travel assessment. And it should also include patient education and comfort measures including safety and pain management.

We should also as clinicians, make every effort and use the available resources that we have. And consider even using bereavement support for the patient and their family.

Also I would consider using a Chaplin or mental health liaison; maybe even a social worker or other ancillary staff experienced in providing psychosocial support.

If a Zika infection is expected, there will most likely be a blood test to detect the virus. CDC labs will analyze the specimen. Patients should be given step-by-step instructions on what to expect, to help with any questions they may have throughout the process.

Most patients presenting to the ED with a potential Zika infection will be stable and will only require referral services with patient teaching.

In some cases an ultrasound may be conducted. And to help support clinicians, the Zika Pregnancy Hotline can be assessed for any questions.

Zika virus disease is a nationally notifiable condition. Healthcare providers should report suspected Zika virus disease cases to their state, local, or territorial health department to facilitate diagnosis and mitigate risk of local transmission.

Each facility or emergency care setting is different and will have different policies and procedures for reporting cases of Zika. So it's really important to follow your institution's policies and procedures.

Designating a health - a designated healthcare staff should report suspected cases to state or local health departments to facilitate diagnosis. So we have to work collaboratively with your physician and infection control prevention group to decide on who's going to be the one to report the case.

Diagnostic testing will be completed by state, local, or territory health departments and will report laboratory confirmed and probably cases to the CDC.

So what emergency care providers -- hang on one second -- so what emergency care providers will be doing is providing patient education and discharge teaching.

Patient education should be targeted to the individual's needs and diagnoses. It's difficult to predict you know, what sort of patient is going to be presenting to the ED. So it's better to be prepared for any potential scenario.

The most important thing to remember is that the information we do provide must be the most up-to-date information from reputable sources.

Clinicians don't have to reinvent the wheel. However the CDC has developed a plethora of resources, both for healthcare providers and information directed for patients.

Most patients presenting an emergency department benefit from Zika basic facts including transmission and information on how to protect themselves.

Depending on the area in which you live, you may want to provide more information on mosquito control and prevention measures.

Pregnant patients or patients who are trying to get pregnant should be provided with travel advisory information, and should always be referred to their OB/GYN for additional concerns.

Additional patient teaching - so patients who have been tested can be provided with step-by-step infographics from the CDC on what happens when someone is tested.

Those suspected of being infected must be cautioned about mosquito exposure during the first week of illness to prevent further transmission.

Men who have traveled from an area with circulating Zika virus, and who have a pregnant partner, should be instructed to abstain from sexual intercourse, or use condoms consistently for the remainder of the pregnancy.

Women planning to become pregnant and who have traveled to a Zika infected area should be instructed to wait at least eight weeks after the last possible exposure.

As for men, as Dr. Hirshon talked about a little bit, they should be instructed to wait at least six months after symptoms start or from the last possible exposure.

Pregnant women who test positive should be referred to Maternal Fetal Medicine specialists for serial fetal ultrasounds and possible fetal testing.

More than likely the patients will have many questions which is, you know, understandable, especially for those who are pregnant and are suspected to have a Zika virus.

If families would like to speak to somebody about a possible Zika virus infection or diagnosis during pregnancy, and what the risks are to the baby, it is advisable to have them contact Mother to Baby for more information in support of care.

As emergency providers, our focus is really on treating the immediate symptoms. We also are accustomed to providing psychosocial support and ensuring we have - we are giving appropriate patient education, discharge information, and referrals.

Keep in mind though that in certain circumstances, in the emergency department we may be the ones responsible for coordinating care with multidisciplinary teams, including home care.

Therefore it's really important to understand your individual hospital policies and procedures including who to contact to help facilitate testing and diagnosis, as well as follow-up care.

When you have an opportunity, please take time to visit the CDC's website for valuable information including clinical guidance.

Thank you for participating on this call. Now I'm going to turn it over to the moderator.

Ashley Ghaffarzadeh: Hi, this is Ashley again. Thank you presenters for providing our COCA audience with a wealth of information.

We will now open up the lines for the question and answer session. Joining us for the question and answer session are Dr. Preeta Kutty, a CDC Healthcare Infection Control subject matter expert, and Dr. Athena Kourtis, a subject matter expert from CDC's Pregnancy and Birth Defects Taskforce.

Questions are limited to clinicians who would like information relate to Zika virus infection. For those who have media questions, please contact CDC Media Relations at 404-639-3286 or send an email to media@cdc.gov. If you are a patient, please refer your questions to your healthcare provider.

When asking a question please state your organization. And also remember, you can submit questions through the webinar system as well. Actually we have a call here - I mean a question here now.

The question is, is there a recommendation for CDC or current presence to do universal screening in the ED? Presenters, are you able to respond to that?

Jon Mark Hirshon: So what I would say is, Zika is a reportable disease. But I do not believe that it's required to do universal screening. And to be honest, I'm not sure that would make sense in many areas, particularly the Northern part of the continental United States.

I'd have to defer to my CDC colleagues. But to my understanding, while it is a reportable disease, screening is not currently required.

Athena Kourtis: Yes, thank you, this is Dr. Kourtis from the Pregnancy and Birth Defects Taskforce. That is correct. The current recommendation is for all pregnant women who have been exposed, either through travel or through sexual exposure, even if asymptomatic, recommendation is for all pregnant women who had exposure to be screened - to be tested but, not universal screening.

Ashley Ghaffarzadeh: Thank you both. Operator can you go ahead and open the lines for questions, please?

Coordinator: Thank you. As stated, if you would like to ask a question, please press star 1. You'll be prompted to record your name. To withdraw your request please press star 2.

Dr. Warner Hudson, your line is now open. And please state your organization.

Warner Hudson: Hi, this is Warner Hudson from UCLA. I'm the Medical Director for Occupational Employee Health for the Health System on the campus.

And just really a comment more than a question. We have a lot of travelers for work and research who go to Zika areas and come back. And we also do live Zika work in our labs.

So we have started doing testing for those with exposures. We do a commercial test. It's I think, a Viracor test, blood and urine PCR early, and IGG IGM later, after exposure or symptoms.

And our lab is doing about ten of these a week. Has had some positives. Of course those would be confirmed with the Public Health Department; CDC type tests.

And I'm just wondering if you've begun to think through the algorithms for these occupational health exposures which certainly do show up in the emergency departments and urgent care when we are closed or people don't happen to come to us, they go to the emergency room. Thanks.

Preeta Kutty: Good afternoon, my name is Preeta. I belong to the Healthcare Infection Control part of Zika response.

Yes, we certainly are looking into that as well. We hope to have some guidance soon. But in the absence of you know, occupational exposure, you know they should follow the guidance that has been provided so far and take - you know, take the necessary precautions. But thank you for raising that question. We appreciate that.

Warner Hudson: Sure. Thank you.

Coordinator: Amy Behrman, please state your organization. Your line is open.

Amy Behrman: Hi, this is Amy Behrman from the University of Pennsylvania and I also would like to make a comment and ask a question about occupational exposure risks. This, not so much for travelers and laboratory researchers but for healthcare workers.

As your presentation pointed out, the risk of occupational exposure in a clinical setting is low. But the - I think we all know that the anxiety that will occur is very high when there's occupational exposure, particularly in settings where a very large proportion of the healthcare workers are women of childbearing age, which is the case for most of us.

My question is, are there any circumstances at this time where you recommend testing source patients in an occupational exposure, needle stick type situation, if there is no preceding clinical suspicion for Zika in the source patient?

Jon Mark Hirshon: This is Jon Mark Hirshon. And I can't speak for the CDC. I'm not aware of anything like that.

But what I would say is, you know, you have to take a look at the risk profile if you're considering testing for something.

So if someone has no travel history, no symptomatology; nothing to make you think of it, I think that that would be a bit of, at least from a clinical perspective, a bit of an overreach.

I do recognize that there's a significant anxiety component to it, and that's something than an individual healthcare provider who has had a needle stick will have to address. And perhaps something that they can follow up with, with their occupational health at their institution.

But I think from a clinical perspective it would not make sense to test someone who is - to do additional tests on a source subject if there's no clinical indication for that.

Amy Behrman: I don't know if I'm still live on the line, but that actually makes complete sense. Because the positive predictive value in that setting would be so low.

I think it does, you know, support the concept that we should be making sure that our institutions are at least double checking the screening questions with source patients, even if the institution is not doing universal screening.

Preeta Kutty: And this is Preeta again from the Infection Control side. As you know, was mentioning earlier recently, there's no risk factor. You know, we don't recommend testing if they don't have some of the risk factors that have been either identified or through your questionnaires. Or you know, we don't really recommend the testing part of it.

We haven't seen any data as yet. However, based on new information that may come and that was mentioned during the presentation, you know there's always the information coming every day. We'll certainly keep everyone posted and up to date. Thank you.

Jon Mark Hirshon: You guys are asking great questions and they're really thoughtful and really kind of are, from a clinical perspective, I think part of the cutting-edge of trying to address this in the emergency department.

Ashley Ghaffarzadeh: Operator, are there any more questions on the line?

Coordinator: (Amy Deso) from Palmetto General Hospital.

Amy Deso: Hello?

Ashley Ghaffarzadeh: Yes, we hear you.

Amy Deso: Yes hi; good afternoon. I wanted to know, what is the recommendation if a mom tested positive? Once the baby is born, what is the recommendation?

Athena Kourtis: This is Athena Kourtis again from CDC, the Pregnancy and Birth Defects Taskforce.

There is guidance that CDC has issued on the evaluation and care of the infant. So mothers with congenital exposure, and we can send that link if you would like.

It really depends on whether the infant has symptoms present at birth or not. And we do essentially recommend that the infant be tested in circumstances where the mother has either laboratory evidence of Zika exposure, or where there's strong suspicion based on epidemiologic links, and the infant has abnormalities that could be consistent with Zika.

And we do recommend that the baby be tested in the first two days of life if possible, or as soon as possible thereafter. And the recommended testing includes serum in urine for PCR and for IGM.

And there's also a number of other evaluations that independents do have including, you know, the head circumference, careful close monitoring of the infant's growth, and eye exam and hearing test. And there's a long list of other things that need to be considered along with congenital Zika infection. We can forward the updated guidance if you would like.

Amy Deso: Yes please, that would be great. But do we have to test the infant even - I know we have to do a very thorough, you know, assessment on the baby.

If the baby shows no sign of symptoms of Zika, do we still have to go ahead and do - is it recommended to do the serum and the urine testing?

Athena Kourtis: We do, you know, if the baby is normal but the mother has laboratory evidence of Zika infection, that really might depend on how - you know, on the discussion between the healthcare provider and the parents, and how comfortable they feel.

We do have some emerging information that infants may appear normal at birth and may have normal head circumference, but they may start develop abnormalities later on.

And we have seen that happen in Brazil and in other settings where the head circumference may fall off the percentile as the infant grows in the first few months of life.

And there are also indications the infant may have other abnormalities that are very subtle such as isolated hearing loss perhaps. So we do want to capture all these infants and we would err on the side of testing all infants where the mother had a convincing case of Zika infection during pregnancy.

Amy Deso: Okay. And one more question; I'm sorry. How long is the recommendation to follow these cases for like the baby? For example if the baby is negative - comes back negative and there's no signs and symptoms, how long is it recommended that the parents continue to follow up?

Athena Kourtis: Well if the infant, you know, has negative testing and appears completely normal in the initial evaluations, so that would include a hearing screen and an eye exam, then you know the baby can have just a routine, you know, infant care.

And the pediatrician, it depends of course, will closely monitor you know, the growth and development of the baby. And then we will feel comfortable having, you know, this routine care for the baby.

Amy Deso: Okay, perfect. Okay, thank you.

Athena Kourtis: Sure.

Ashley Ghaffarzadeh: Operator, any more questions?

Coordinator: Your line is open.

Pam Alexander: Hi, this is Pam Alexander, Infection Preventionist from the West Palm Beach VA, and my question isn't directly about ER, but I do have a question about you know, Guillain-Barre. You know, to have a patient who presents with Guillain-Barre with just living in an area where there are localized, albeit low, transmission - have been local transmission. Do you think it appropriate to test them just for epidemiologic reasons?

Jon Mark Hirshon: From a clinical and epidemiological perspective I think it would be reasonable to test them.

And I would probably go a little further in that if you have someone, especially if they have recent symptomatology that makes you concerned, that you have to consider that they are at risk for, you know, transmission.

So I would probably, you know, at least start from isolation, if you've got the appropriate epidemiological kind of background.

So when someone has traveled there or you're in an area where there's transmission, then I would think it appropriate to test them. Because Guillain-Barre is still a relatively unusual condition. And especially has recent, you know, viral type of infections.

Pam Alexander: It's really not - it's not a specific indication that we were discussing here did not have any clinical presentation that had enough specificity for the health department to want to test him. But there was some unknown illness and - anyway, I just wondered if you thought, even without - in the absence of symptoms, would you still feel the prudence to test them?

Jon Mark Hirshon: If I haven't - if I'm concerned from an epidemiological perspective. So if I think that there is - they've got risks because of recent travel, sexual contact, or endemic within the area, then I would consider that as part of my panel.

If I had any concerns or wasn't sure, then I would check with my infectious disease colleagues at my institution.

Pam Alexander: Yes. Thank you very much.

Coordinator: I show no further questions.

Ashley Ghaffarzadeh: Okay, this is Ashley. I have something that came in through the question and answer webinar option.

We have (Julia Shackner). She says, thank you for the presentation. I think I might have heard one of the speaker's mention that only health department labs and CDC can test for Zika.

But just wanted to clarify that there are some commercial lab testing for Zika virus currently. Both LabCorp and Quest offer RT-PCR and MAC-ELISA IgM Zika tests.

Jon Mark Hirshon: And it's true, there are no formally commercially approved tests, but there are FDA approved emergency use tests available. So some labs will be using those tests. They're not - again they're approved on kind of an emergency use process.

And so from a recording or documentation perspective, I think the reporting process will go through the local health departments.

Ashley Ghaffarzadeh: Thank you. Well at this time Dr. Satish Pillai will provide closing remarks, and I will follow with instructions for continuing education.

Satish Pallai: Thank you Ashley and thank you to our speakers today. Today we've learned the role of emergency departments and how they can assist in the current response to the Zika outbreak that we've seen.

We hope today's presentations will assist you as you manage patients in your busy practices. As emergency providers you have significant interactions with members of your community, and can have a role to play in screening for Zika exposures, as well as diagnosing and reporting Zika.

Screening for relevant travel or sexual exposure history, and understanding the constellation of potential symptoms can help inform decisions regarding the role of testing and the type of testing that may be appropriate.

And you can help provide the appropriate prevention strategies to reduce the risk of mosquito-borne transmission and sexual transmission. All of these activities are of particular importance for our most vulnerable population of pregnant women.

So once again, thank you for participating and please do visit the CDC website if you have any questions regarding what's new, and, for CDC's latest guidelines. Thank you.

Ashley Ghaffarzadeh: The recording of this call and the transcript will be posted to the COCA website at emergency.cdc.gov/coca within the next few days. All Continuing Education for COCA calls are issued on line through the TCE Online, the CDC Training and Continuing Education online system at www.cdc.gov/tceonline.

Those who participated in today's COCA call and would like to receive Continuing Education should complete the online evaluation by December 5, 2016 and use the course code, WC2286.

Those who will review the call On Demand and would like to receive Continuing Education should complete the online evaluation between December 6, 2016 and December 6, 2018, should use course code WD2286.

To receive information on upcoming COCA calls, subscribe to COA by going to the COCA webpage at emergency.cdc.gov/coca and clicking on the, Join the COCA Mailing list link.

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Thank you again for being part of today's COCA call. Have a great day.

Coordinator: This concludes today's conference call. Thank you for participating. You may disconnect at this time.

END