Epidemiologi, internationella rekommendationer. Anders Tegnell, Statsepidemiolog

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1 Epidemiologi, internationella rekommendationer Anders Tegnell, Statsepidemiolog

2 Innehåll Geografisk riskbedömning Risk Guillaine- Barre syndrom Reserådgivning i Sverige Sid 2. 10/5/2016

3 Zika grundfakta Zika en zoonos Virus i en sjuk persons blod kan infektera en mygga Myggan kan sen sprida viruset till andra mottagliga personer. Mild sjukdom Sid.

Zika virus Belongs to Genus Flavivirus, family Flaviviridae Enveloped icosahedral Single stranded RNA virus Two lineages: African and Asian Tick-borne encephalitis

4 Zika virus Belongs to Genus Flavivirus, family Flaviviridae Enveloped icosahedral Single stranded RNA virus Two lineages: African and Asian Tick-borne encephalitis virus West Nile Virus Murray Valley Encephalitis Virus Japanese Encephalitis Virus St. Louis Encephalitis Virus DENV 1 DENV 3 DENV 2 DENV 4 Yellow Fever Virus Zika Virus Sid.

5 Transmission Vector borne transmission by Aedes mosquitoes Sylvatic vector in Africa: Aedes spp. Primary vector in urban settings: Aedes aegypti Competent vector: Aedes albopictus Other routes of transmission Trans-placental transmission Sexual transmission through semen Potential risk of transmission via blood transfusion Sid. 5

6 Zikavirus - blodgivning etc. Karantänstid Vem ansvarar? Blod 28 dagar SoS Spermier 6 månader SoS Äggdonation?? SoS Levande donation njure - lever?? SoS Sid

7 Zika Virus Pregnancy related Complications Sid.

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11 Geografiska risker Länder med omfattande utbrott Länder med mycket myggor Länder där få eller inga har immunitet Brasilien mfl Länder med endemisk zika Myggor Låg nivå av ständig smitta eller möjligen sylvatisk smitta Lite oklart men troligen större delen av Asien Afrika etc Övriga Inga myggor Enstaka importfall med risk för sexuell spridning Ingen pågående spridning Sid /5/2016

12 Brasilien misstänkta fall per vecka Sid /5/2016

13 Brasilien Sid /5/2016

14 Colombia Sid /5/2016

15 Colombia Sid /5/2016

16 GBS Most commonly, infection with campylobacter, a type of bacteria often found in undercooked poultry Influenza virus Epstein-Barr virus HIV, the virus that causes AIDS Mycoplasma pneumonia Surgery Hodgkin's lymphoma Rarely, influenza vaccinations or childhood vaccinations Sid /5/2016

17 GBS i Brasilien Sid /5/2016

GBS Syd- och Centralamerika 2015-2016 dos

18 GBS Syd- och Centralamerika dos Santos et al NEJM 2016 Sid

19 Reseråd Sid /5/2016

20 Vem ger reseråd i Sverige Den som säljer resor har ett ansvar för att informera om risker med produkten Normalt löses detta genom hänvisning till vaccinations/resemottagning. Deras underlag bygger på Fakta från ett av två underlag från privata aktörer Diverse web mm Folkhälsomyndigheten underrättar om större epidemier od För personer med annan kontakt med vården (kronisk sjukdom, graviditet mm) kompletteras/ersätts detta med kontakt med sjukvården för råd utifrån personliga förutsättningar Råden omsätts i vaccinationer och andra råd om hur resan kan genomföras eller inte genomföras på säkrast möjliga sätt Nationella avrådan från resa görs av utrikesdepartementet, UD, på underlag av olika myndigheter, bland annat Folkhälsomyndigheten. En avrådan kan göras vid allvarliga situationer i länder som gör att man helt bör undvika att resa dit. Rekommendationen från UD får bland annat konsekvenser för hur man kan få ersättning för inställda resor då detta inte ersätts av normala försäkringar force majeur Sid

21 Association zikavirus kongentitala missbildningar Sambandet stärks med nya data Sannolikt är infektion i första trimestern mest relevant, data finns ej Data saknas på hur många infekterade som drabbas och om symtomatologi har betydelse 12/42 pos 29% 0/16 neg Sid

22 ECDC CDC WHO WHO has issued no general restrictions on travel or trade with countries, areas and/or territories with Zika virus transmission. Brasilien Pregnant women should postpone non-essential travel to areas with widespread transmission - Pregnant women should not travel to area of Brazil below 6,500 feet - Women and partners thinking about pregnancy: do not travel to areas with zika WHO is advising pregnant women not to travel to areas with ongoing Zika virus oubreaks Florida Pregnant women should postpone non-essential travel to areas with widespread transmission Pregnant women and their sex partners who are concerned about potential exposure may consider postponing nonessential travel to Miami-Dade County. WHO is advising pregnant women not to travel to areas with ongoing Zika virus oubreaks Singapore Pregnant women should postpone non-essential travel to areas with widespread transmission - Pregnant women should not travel to Singapore. - Women who are trying to become pregnant: talk to your doctor, see CDC guidance for how long you should wait to get pregnant after Singapore. WHO is advising pregnant women not to travel to areas with ongoing Zika virus oubreaks Thailand Pregnant women should postpone non-essential travel to areas with widespread transmission Pregnant women or planning to become pregnant should discuss with their doctor and consider postponing nonessential travel to Thailand?? Tanzania Sid Pregnant women should consider postponing nonessential travel to areas with sporadic transmission The risk in endemic countries is likely much lower than in countries with Zika epidemics; pregnant women should consult with doctor and, if they decide to travel, prevent mosquito bites.??

23 Current situation: worldwide Americas: Caribbean: Africa:? SE Asia: Pacific: Sid. Source:

Situation in Florida, as of 9 September 616 imported cases 56 autochthonous cases - 49 in Miami-Dade county - 1 in Broward county - 3 in Palm Beach county - 1 in Pinellas (Tampa area) - 2 under

24 Situation in Florida, as of 9 September 616 imported cases 56 autochthonous cases - 49 in Miami-Dade county - 1 in Broward county - 3 in Palm Beach county - 1 in Pinellas (Tampa area) - 2 under investigation 3 Aedes aegypti mosquito positive samples in Miami Beach 95 samples tested negative Sid. Source: Florida Department of Agriculture and Consumer Services ; Department of Health Daily Zika Update

25 Zika cases reported in continental EU/EEA, as of week 35 No 1552 travel-associated Zika virus infections from 19 countries 79 among pregnant women 4 cases reported as sexual transmission ( (IT, PT, ES) No vector borne transmission in the EU) from e.g. Sid.

26 Zikavirus - maximala detektionstider Virus mätbart efter symptomdebut Virus mätbart före symptomdebut PCR = zika-rna Virusodling Serum EDTA 58 Urin Sädesvätska Saliv Cervikalsekret 11 Bröstmjölk 8 4 Sid

27 Presence of ZIKV in semen (detection by RT-PCR) Overview of follow-up of 20 patients Infectious virus recovered from semen after 24 days (D Ortenzio, 2016). Longest duration between onset of symptoms and sexual transmission 41 days (Turmel, 2016) Sid.

28 Jämförelse av rekommendationer gällande sexuell överföring av zikavirus ECDC CDC WHO FoHM Män Symptomatisk 6 månader 6 månader 6 månader 6 månader Asymtomatisk 8 veckor 6 månader 6 månader 6 månader Kvinnor Symptomatisk 8 veckor 8 veckor 6 månader 6 månader Asymtomatisk 8 veckor 8 veckor 6 månader 6 månader Sid.

29 Current evidence sexual transmission As of 26 August 2016, a total of 17 studies or reports have been published on sexual transmission of Zika virus. 12 countries reported events of none-mosquito-borne Zika virus sexual transmission since February 2016* No. of case Case reports Comments reports Symptomatic male to female transmission 7 Male to male transmission 1 Female to male Asymptomatic male to female transmission 2 1 Most of the event: probable few days before, during or after symptoms onset in primary case ( in general < 20 days). One article reported 3 events of transmission. Both primary and secondary case are symptomatic. Unprotected sexual intercourses before and just after symptoms onset in the primary case. Both primary and secondary case are symptomatic. Single unprotected sexual intercourse the day before onset of symptoms of primary case. Freour et al.: Probable T. Two asymptomatic cases. (observation from Assisted Reproduction Treatment centre (semen detection + in primary case). Serum and urine by rrt-pcr 39 days after return from affected area. Brooks et al: Primary case asymptomatic, secondary case symptomatic without any possible vector-borne transmission Four case-reports reported by International Health Regulations National Focal Points but date of sexual exposure not available. In all reports, both primary and secondary case are symptomatic. Two case-reports described through government/news media (No details available about sexual exposure) * WHO Sid AMRO/PAHO. (Argentina, Canada, Chile, Peru, United States of America); WHO EURO (France, Germany, Italy, Netherlands, Portugal, Spain) and WPRO (New Zealand) Source: WHO Interim guidance update 6 September 2016, ECDC Scoping review ( Zika AND Sexual transmission )

30 3 million per year 2 million in next 6 months Germany, United Kingdom, France, Sweden, Italy, Denmark >100,000 travellers 78% of travel Sid.

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