With evidence that sexual transmission of the Zika virus has occurred, public health officials are moving quickly to inform the public and educate healthcare professionals on disease prevention.
In light of the increased risk, the WHO has updated its guidance and recommended that couples or women planning pregnancy who live in or are returning from Zika-affected areas wait at least eight weeks before trying to conceive to ensure the virus has cleared their bodies. The organization previously had recommended a four-week minimum period before trying to conceive in such circumstances.1 (This information was posted May 31, 2016, by AHC Media, publisher of Contraceptive Technology Update. To keep up with breaking news as it happens, go to reliasmedia.com.) Concern about the virus has grown since an association has been established between Zika virus infection and adverse pregnancy and fetal outcomes, including microcephaly, neurological complications, and Guillain-Barré syndrome.
To provide a more complete picture of the effects of Zika on pregnant women in the U.S. states and territories, the CDC has changed its reporting system.2 The CDC system previously included only pregnant women with symptoms or pregnancy complications consistent with Zika; the new system now includes pregnancy data from two enhanced surveillance systems: the U.S. Zika Pregnancy Registry and the Puerto Rico Active surveillance system. Both of these systems include pregnant women with any laboratory evidence of possible Zika virus infection with or without symptoms.
Recent published studies indicate that there are babies with microcephaly that have test results suggesting Zika infection, but whose mothers didn’t recall having any symptoms of Zika, explains Margaret Honein, PhD, MPH, CDC epidemiologist and chief of the its Birth Defects Branch. As of June 9, 2016, the CDC is reporting the number of pregnant women with any laboratory evidence of possible Zika virus infection, with or without symptoms, from the United States and Washington, DC, is 234, with 189 reported in United States territories.
“This comprehensive information will assist healthcare providers as they counsel pregnant women affected by Zika,” said Honein at a CDC press conference. “It is also essential for planning at the federal, state, and local levels for the clinical public health and services needed to support pregnant women and families affected by Zika.”
What Is Known
What is known about sexual transmission of the Zika virus? The CDC has hosted teleconferences to address Zika information; sexual transmission has been discussed in these teleconferences. The Zika virus can be found in a man’s semen longer than in his blood, according to John Brooks, MD, senior medical advisor in the CDC’s National Center for HIV, Viral Hepatitis, STD and Tuberculosis Prevention. However, public health officials do not know:
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how long the virus can stay in the semen of men who have had Zika virus or how long it can be transmitted to a sex partner;
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the pattern or frequency of shedding in semen: if it’s intermittent (sheds some days, other days not) or, if it declines, then how it declines (rapidly, slowly, linearly, or logarithmically);
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if the Zika virus can be spread from other body fluids exchanged during sex, such as saliva and vaginal fluid.
While the Zika virus can be spread through sex by a man who has the virus to his male and female partners through vaginal sex, anal sex, and oral (mouth-to-penis) sex, scientists don’t know if women with Zika can spread the virus to their sex partners, said Brooks during a recent teleconference on the subject.
In all known cases of sexual transmission, the men developed Zika symptoms, observes Brooks. Men have transmitted Zika shortly before, during, and after symptoms developed. Yet, it is not known if men who never develop Zika symptoms — those who are asymptomatic — can have the Zika virus in their semen and transmit it to partners during sex. Scientists also don’t know if asymptomatic men shed virus in semen with the same frequency, duration, and pattern as symptomatically infected men, states Brooks.
Who should be tested for the Zika virus? The CDC recommends testing patients with fever, rash, arthralgia, or conjunctivitis whose symptoms onset during or within two weeks of travel to an area with ongoing transmission, OR have an epidemiologic link to a laboratory-confirmed case through vertical transmission, sexual contact, or association in time and place.
Also, offer testing to asymptomatic pregnant women with a history of travel to an area with ongoing transmission OR sexual contact with a partner who had symptoms of Zika virus disease during travel or within two weeks of return from an affected area.
Testing is NOT recommended to establish risk of sexual transmission in men until more is known more about Zika shedding in semen, says Brooks. Negative results might be falsely reassuring, because Zika can persist in semen after it is no longer detectable by reverse transcription polymerase chain reaction in blood, he notes.
The CDC’s recommendations for pregnant women and their male partners (couples in which a man has traveled to or resides in an area with active Zika virus transmission) is to use condoms consistently and correctly or abstain from sex for the duration of the pregnancy. This recommendation includes vaginal, anal, and oral (mouth-to-penis) sex.
“This recommendation is our strongest recommendation and does not change based on whether the woman lives in a Zika affected area, has a male partner who travels to or lives in a Zika affected area, whether the male partner has symptoms, or if he tests positive/negative for Zika,” says Brooks.
How to Talk About Zika
Talking about the sexual transmission of Zika virus can be complicated, notes Brooks. Providers should give the following instructions that are clear and unambiguous:
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If concerned about Zika, couples can use condoms or choose not to have sex. This step is highly recommended during pregnancy for women with male sex partners who have lived in or traveled to an area with the Zika virus.
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To be effective, condoms must be used correctly from start to finish, every time, during sex.
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Sex includes vaginal, anal, and oral (mouth-to-penis) sex.
Couples who don’t desire pregnancy should use the most effective contraceptive methods that can be used correctly and consistently in addition to condoms, which can prevent transmission of Zika and also are effective against sexually transmitted infections, says Brooks.
Talk with patients about condom skills, advises Brooks. Emphasize the importance of practice, as well as the use of the proper lubricant: water- and silicone-based, not oil-based, lubricants.
Make condoms available and accessible at your facility, states Brooks. Assess potential demand and current stock, and prepare a plan to acquire, distribute, and promote condoms if they are needed. (The CDC has fact sheets and posters on the Zika virus at http://1.usa.gov/1Ws7NV3. Use the free patient handout on how to use a male condom. Download it from the CDC website at http://1.usa.gov/1UoyGs1. Also, check the AHC Media resources in the “Resources” section at the end of this article.)
Robert A. Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta, notes that the CDC and WHO have assiduously avoided discussion of abortion as an option for women infected or possibly infected with the Zika virus. “I am certain that this is not an accident,” says Hatcher. “I am also certain that discussion of pregnancy termination should be part of the care provided to women at risk of becoming infected by the Zika virus.”
REFERENCES
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World Health Organization. Prevention of sexual transmission of Zika virus. Interim guidance update. Accessed at http://bit.ly/1RahnrK.
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Fischer M. Zika Virus Disease Surveillance in U.S. States. Accessed at http://1.usa.gov/28IYP5L.
RESOURCES
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AHC Media, publisher of Contraceptive Technology Update, is committed to keeping clinicians up-to-date on the Zika virus. Visit reliasmedia.com/Zika for the latest information. Also, readers can take advantage of our on-demand webinar, “The Zika Virus: Separating Fact from Fiction — A Discussion with Experts,” by going online to http://bit.ly/28JkUyo.
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The Association for Reproductive Health Professionals offers a Zika information center that is online at www.arhp.org/zika. Updated daily, it includes links to all WHO and CDC recommendations, as well as the latest clinical research and media articles.
