Journal of the Formosan Medical Association (2016) 115, 226e242

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REVIEW ARTICLE

Zika virus infectiondthe next wave after

dengue?
Samson Sai-Yin Wong a,*, Rosana Wing-Shan Poon b,
Sally Cheuk-Ying Wong b

a
Department of Microbiology, Research Centre for Infection and Immunology, Faculty of Medicine, The
University of Hong Kong, Hong Kong
b
Department of Microbiology, Queen Mary Hospital, Hong Kong

Received 16 February 2016; accepted 17 February 2016

KEYWORDS Zika virus was initially discovered in east Africa about 70 years ago and remained a neglected
Zika virus; arboviral disease in Africa and Southeast Asia. The virus first came into the limelight in 2007
Flavivirus; when it caused an outbreak in Micronesia. In the ensuing decade, it spread widely in other Pa-
Aedes; cific islands, after which its incursion into Brazil in 2015 led to a widespread epidemic in Latin
travel medicine; America. In most infected patients the disease is relatively benign. Serious complications
congenital include GuillaineBarré syndrome and congenital infection which may lead to microcephaly
abnormalities and maculopathy. Aedes mosquitoes are the main vectors, in particular, Ae. aegypti. Ae. albo-
pictus is another potential vector. Since the competent mosquito vectors are highly prevalent
in most tropical and subtropical countries, introduction of the virus to these areas could
readily result in endemic transmission of the disease. The priorities of control include reinfor-
cing education of travellers to and residents of endemic areas, preventing further local trans-
mission by vectors, and an integrated vector management programme. The container habitats
of Ae. aegypti and Ae. albopictus means engagement of the community and citizens is of
utmost importance to the success of vector control.
Copyright ª 2016, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

Conflict of interest: The authors have no conflicts of interest relevant to this article.
* Corresponding author. Department of Microbiology, LG-1 Block K, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong. Tel.: þ852 2255
3206.
E-mail address: [email protected] (S.S.-Y. Wong).

http://dx.doi.org/10.1016/j.jfma.2016.02.002
0929-6646/Copyright ª 2016, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Zika virus infection 227

Introduction the clinically relevant pathogens belong to the genus Fla-

vivirus. Epidemiologically, the arthropod-borne flaviviruses
The past decades have seen some hitherto exotic arbovi- can be divided into mosquito-borne and tick-borne viruses.
ruses and other arthropod-borne infections emerging from Flaviviruses with no known vectors are also found in ani-
oblivion into epidemic diseases of global concern. The mals. Clinically, the most prominent syndromes caused by
burden of dengue has been rising for five decades.1 The flaviviruses are undifferentiated febrile illnesses (often
2004e2005 outbreak of chikungunya in East Africa and In- presenting as a fever with rash syndrome), central nervous
dian Ocean was followed by worldwide spread in both the system infection (especially encephalitis), visceral
Old and New Worlds in the ensuing decade.2 The expanding involvement, and haemorrhagic fever.
geographical distribution of these arboviral diseases is Flaviviruses are enveloped, single-stranded, positive
further fuelled by climate changes and importation of sense RNA viruses measuring about 50 nm in size. The viral
invasive arthropod species (most notably various Aedes genome is about 10.5 to 11 kbp in size.12,13 The viral
mosquitoes such as Ae. albopictus, Ae. japonicus, Ae. genome produces a polyprotein with more than 3000 amino
aegypti, and Ae. koreicus) into temperate countries of acids; this polyproptein is then cleaved into three struc-
Europe and North America.3,4 The consequences of climate tural and seven non-structural proteins.10 The flaviviral
change and vector distribution can be seen in the autoch- genome encodes (from 50 to 30 end, i.e. from N- to C-ter-
thonous transmission of dengue and chikungunya in high- minal of the polyprotein) the structural C (capsid,
latitude areas such as Japan and European countries.5,6, w11 kDa), prM (precursor M protein, w26 kDa, which is
Zika virus is the latest culprit in a long list of arbovirus further cleaved into the M protein), and E (envelope,
epidemics that emerged in the past two decades. As a w53 kDa) proteins, and the non-structural NS1 (w46 kDa),
largely neglected disease, little is known about the basic NS2A (w22 kDa), NS2B (w14 kDa), NS3 (w70 kDa), NS4A
biology of the virus and the disease until the past decade (w16 kDa), NS4B (w27 kDa), and NS5 (w103 kDa) pro-
when it made its mark outside Africa, not to mention vac- teins.10 Structurally, the E and M proteins are
cine development and antiviral studies. At the time of located at the surface of the viral particles, while the
writing (early 2016), the epidemic in Latin America is still nucleocapsid is made up of the C protein and the genomic
evolving. As in the case of other emerging epidemics such RNA molecule.
as chikungunya, new clinical and laboratory features may Table 2 summarizes the key functions and host effects of
be recognized which may impact on future management of the flaviviral proteins. It must be remembered that the
the disease. We herewith summarized what is currently current knowledge on the effects of various viral proteins
known about the infection, highlighted the uncertainties, on host immune system and pathogenesis is based on pre-
and examined the approaches to prevention and control of vious studies on clinically important flaviviruses such as
similar arthropod-borne infections which are pertinent to dengue virus, West Nile virus, yellow fever virus, Japanese
areas with risks of disease introduction and transmission. encephalitis virus, and tick-borne encephalitis virus.
Whether the findings can be generalized to other flavivi-
ruses including Zika virus is unknown.
Virology Initial isolation of Zika virus was made from a sentinel
rhesus monkey in 1947 in the Zika Forest area of the
The family Flaviviridae contains some of the most clinically Entebbe Peninsula in Uganda on the northwestern shore of
important arboviruses (Table 1). The prototype agent, Lake Victoria.28 In 1948, the virus was also detected in a
yellow fever virus, is indeed the first human virus discov- batch of Aedes africanus mosquitoes.28 Isolation of the
ered and found to be transmitted by an arthropod vector.7,8 virus from humans were then reported in Uganda, Tanzania,
There are currently four genera in Flaviviridae, Flavivirus and Nigeria in the 1950s.29,30 The genomes of the three
(53 species), Hepacivirus (one species, the hepatitis C human isolates of Zika virus are 10,676 bp in size, which is
virus), Pegivirus (two species), and Pestivirus (four spe- comparable to other members of Flaviviridae.31 Zika virus
cies).9 With the exception of the hepatitis C virus, most of is phylogenetically closest to the Spondweni virus, which is

Table 1 Key clinical and epidemiological features of important flaviviruses causing human infections.10,11
Main clinical syndromea Vectors
Mosquito-borne Tick-borne
Central nervous system Japanese encephalitis virus, Murray Valley Louping ill virus, Powassan virus,
infection encephalitis virus, Ntaya virus, Rocio virus, tick-borne encephalitis virus
St. Louis encephalitis virus, Usutu virus,
West Nile virus
Viscerotropic Yellow fever virus, dengue virus Alkhumra virus, Kyasanur Forest
infections  haemorrhagic disease virus, Omsk haemorrhagic
fever fever virus
Febrile illnesses Dengue virus, Ilheus virus, Kokobera virus,
Spondweni virus, Zika virus
a
Overlaps in the clinical syndromes do occur for individual viruses.
228 S.S.-Y. Wong et al.

Table 2 Key proteins of flaviviruses and their functions.10,14e27

Proteins Functions Possible effects on hosts
C RNA binding to form the nucleocapsid.
prM, M Stabilization, assisting the folding and secretion of Antibodies towards prM enhances infectivity of immature
E protein. virions, could be involved in pathogenesis of severe
dengue in secondary infections.
E Receptor binding, membrane fusion.
NS1 RNA replication. Localization to host cell surface and secreted extracellularly;
modulates signalling of innate immune system, possible
damages to platelets and endothelial cells through anti-NS1
antibodies, antagonizes C4 complement.
NS2A RNA synthesis and viral assembly. Interferon antagonist, induces host cell apoptosis.
NS2B Complexes with NS3 to function as serine protease.
NS3 Complexes with NS2B to function as serine protease; Induces apoptosis of host cells, modulates host microRNA,
possess RNA helicase and triphosphatasae activities. one of the targets of cytotoxic T cell response.
NS4A RNA replication. Blocks type I interferon signalling, induces autophagy and
protects host cells from death during infection.
NS4B RNA replication. Blocks type I interferon signalling and RNA interference,
modulator of stress granules in host cells.
NS5 Methytransferase and RNA guanylyltransferase Blocks type I interferon signalling.
activities; capping and synthesis of RNA;
RNA-dependent RNA polymerase.

also a mosquito-borne flavivirus that has been found to diseases), and geographical distribution of the viruses.12
cause a febrile illness in Africa.32 Figure 1 shows the phylogenetic relationship of the clini-
Several flaviviruses are noted for their propensity to cally relevant flaviviruses found in humans. As expected,
cause central nervous system infections, in particular, en- phylogenetic trees based on NS5 and E sequences showed a
cephalitis (Table 1). Globally, Japanese encephalitis virus, clear clustering of the mosquito-borne versus tick-borne
Murray Valley encephalitis virus, St. Louis encephalitis viruses, and viruses that cause central nervous system in-
virus, West Nile virus, and tick-borne encephalitis (and to fections are also clustered together. Although Zika virus
some extent, dengue virus, though neurological involve- does possess neuropathogenic potentials, at least in the
ment is generally not a common feature of dengue) are the immature nervous system, it is not particularly closely
most commonly encountered pathogens in this regard.33 In related to other encephalitic viruses. It might be noted that
addition to the wild-type viruses, even apparently attenu- the other potential serious complication of Zika virus
ated vaccine strains may still possess some degree of neu- infection, Guillain-Barré syndrome (vide infra), also affects
rovirulence, as demonstrated by the yellow fever 17D the nervous system, albeit probably via a different patho-
vaccine.34 The exact genetic determinants of flaviviral genic mechanism. Moreover, in infants with congenital
neurovirulence have not been completely elucidated, infection, abnormalities of the retina (which is essentially a
though it appears to be related to multiple genes such as E, part of the central nervous system) were also detected
NS1, NS3, and NS5.33,35e41 This area is particularly relevant (vide infra). Whether the phylogeny explains why Zika virus
to Zika virus infection which was previously considered to is not highly neurovirulent in adults but causes substantial
be a relatively harmless febrile illness with low case- damage to the immature neural tissues and possibly induces
fatality ratio, but microcephaly has emerged as a unique immunopathological damage in the adult nervous system
potential sequel of the infection in pregnant women during remains to be studied. Another question begging for an
the Latin American epidemic that began in 2015. Although answer is whether both lineages of Zika virus are equally
the exact causality, risk, and mechanism between the neurovirulent for the foetal brain. This is relevant because
infection and microcephaly remain to be investigated, a the Yap 2007 strain and the Senegal 1984 strain of Zika virus
recent report described the presence of Zika virus in the differ from the prototype Uganda strain in that the latter
brain tissues of an affected foetus as demonstrated by both has a four amino acid deletion in the E protein.44 Micro-
reverse transcription polymerase chain reaction (RT-PCR) cephaly has not been reported previously in Africa where
and electron microscopy.42 the disease is endemic (although the possibility of under-
The phylogenetic relationships of flaviviruses have been reporting cannot be excluded). Whether the difference in
well studied.12,13,43 Phylogeny is most commonly studied by the four amino acids or other genetic changes is associated
NS5 sequences, but the NS3 and E sequences or the entire with virulence or transmissibility is currently unknown.
coding region have also been utilized for studies. In gen- Figure 1 also shows a clear separation of Zika viruses into
eral, clustering of flaviviruses can be seen in phylogenetic the African and Asian lineages.45 It has been suggested that
trees based on the type of transmission vectors (mosquitoes Zika virus originated in east Africa near Uganda, which
[Aedes versus Culex], ticks, or no known vectors), type of subsequently spread to west Africa and central Africa (the
clinical syndromes (encephalitic versus non-encephalitic African lineage).46 The Uganda strain also spread to
Zika virus infection 229

Figure 1 Phylogenetic trees showing the relationships between important flaviviruses causing human infection. A total of 1,536
nucleotide positions in envelope (E ) gene (Figure 1A), 1,067 nucleotide positions in non-structural protein 1 (NS1) (Figure 1B), 1,925
nucleotide positions in non-structural protein 3 (NS3) (Figure 1C), 2,736 nucleotide positions in non-structural protein 5 (NS5) genes
(Figure 1D) were included in the analysis. The trees were constructed using the neighbour-joining method. The bootstrap values
calculated from 1,000 trees are shown when they are 70%. The scale bar indicates the estimated number of substitutions per 20 bases
in E and NS3 and per 50 bases in NS1 and NS5. The names and accession numbers (in parentheses) are presented as cited in the GenBank
database. * Mosquito-borne neurotropic viruses; y tick-borne neurotropic viruses; z tick-borne haemorrhagic fever viruses.
230 S.S.-Y. Wong et al.

Figure 1 (continued).
Zika virus infection 231

Table 3 Outbreaks of human Zika virus infection since 2007.59e63

Year Location Estimated number of cases Notable features
2007 Yap Island, 49 confirmed, 59 probable, and 72 suspected Aedes hensilli implicated as the main vector.
Micronesia cases in one study. Estimated over 900 clinical
cases, 73% of population infected in 4 months.
2007 Gabon Detected in 5 archived human samples; total Retrospective study of a concurrent outbreak
number of cases unknown. of dengue and chikungunya; detection of virus
in patient sera and Ae. albopictus pools.
2013e2014 French 8,723 suspected cases, over 30,000 sought Derived from the Asian lineage, closely related
Polynesia medical care. to Cambodia 2010 and Yap state 2007 strains.
Association with Guillain-Barré syndrome and
other neurological complications suspected.
2014 The Cook Islands 932 suspected, 50 confirmed cases.
2014 New Caledonia 1400 confirmed cases (35 imported).
2014 Easter Island 51 confirmed out of 89 suspected cases from Infecting strain closely related to viral strain
Jan e May 2014. found in French Polynesia.
2015 Latin Americaa Estimated 1.5 million cases in Brazil. Association with microcephaly and maculopathy
suspected.
a
As of 10 February 2016. Includes Barbados, Bolivia, Colombia, Commonwealth of Puerto Rico, Costa Rica, Curacao, Dominican
Republic, Ecuador, El Salvador, French Guiana, Guadeloupe, Guatemala, Guyana, Haiti, Honduras, Jamaica, Martinique, Mexico,
Nicaragua, Panama, Paraguay, Saint Martin, Suriname, U.S. Virgin Islands, Venezuela.

Malaysia and the Micronesia, thereby establishing the Asian returning from endemic areas.51e58 The first major
lineage. The Yap outbreak in 2007, French Polynesian epidemic outside Africa occurred in Yap Island of the
outbreak in 2013e2014, and the Latin American epidemic Federated States of Micronesia (in the western Pacific
since 2015 were due to viruses belonging to the Asian Ocean, north to Papua New Guinea) in 2007 (Table 3). Since
lineage, probably originating from a strain from Southeast then, Zika, dengue, and chikungunya viruses became
Asia.44,45,47 rampant in the Pacific islands.61 Another major epidemic
The pathogenesis of Zika virus infection in humans is occurred in the western Pacific islands of French Polynesia
poorly understood, though studies are starting to unravel and New Caledonia in 2013e2014.64
the disease process. In a study on the effects of Zika virus, The outbreak in Easter Island in 2014 heralded the
human skin cells, the fibroblasts, keratinocytes, and den- incursion of the virus to mainland Latin America.62 Since
dritic cells are all permissive to infection with replication of early 2015, Brazil reported the first autochthonous case in
the virus.48 Molecules such as DC-SIGN, AXL, Tyro3, and the city of Natal and this was quickly followed by another
TIM-1 are involved in cell entry, and both type I and type II large epidemic in Brazil and neighbouring countries in Latin
interferons inhibit viral multiplication. The utilization of America.63,65e68 As of 12 February 2016, there were over
multiple cellular receptors for entry is similar to dengue 2,000 confirmed and over 118,000 suspected cases in the
virus. Another study described the cytokine profiles of six Americas.69 The exact time and route of spread of the virus
travellers who acquired Zika virus infection in Southeast to Brazil is unknown, but importation during the 2014 World
Asia, French Polynesia, and Latin America.49 Significant Cup has been postulated.65
elevation of multiple cytokines (including interleukins 1b, The virus is epizootic and enzootic in non-human pri-
2, 4, 6, 9, 10, 13, 17, and IP-10) was observed during acute mates in Africa (sylvatic cycle), and these mammals are the
infection, but not interferon-gamma or tumour necrosis most important natural reservoir hosts.70 However, as in
factor-alpha, suggesting a cytokine response towards Th2 the case of other arboviruses such as dengue and yellow
reaction. Interleukins 1b, 6, 8, 10, 13, IP-10, RANTES, MIP- fever, urban cycles involving humandmosquitodhuman
1a, MIP-1b, VEGF, FGF, and GM-CSF were elevated during transmission can readily occur when there are competent
the convalescent phase. The “cytokine storm” which occurs anthropophilic vectors. Aedes mosquitoes are the primary
in some other viral infections was not demonstrated in the vectors for natural transmission of the Zika virus. The
small cohort of subjects. extrinsic incubation period of the virus in mosquitoes is
about 10 days (similar to the 8e12 days required of dengue
virus).50,71 In Ae. aegypti, high levels of viruses could be
Epidemiology and transmission found within the mosquitoes from days 20e60 after infec-
tion, though the average lifespan of female Ae. aegypti
Since its initial discovery, early virological and serological adults is shorter than this in the tropical field condi-
studies from the 1950s to 1980s showed that Zika virus tions.71,72 Species from which the virus has been isolated or
infection is predominantly limited to African and Asian found to be capable of transmitting the virus include Ae.
countries.50 In Asia, endemic circulation of the virus (clin- africanus (chiefly a forest-dwelling mosquito feeding on
ical disease and/or seroprevalence studies) has been re- non-human primates), Ae. apicoargenteus (an African
ported in Indonesia, Cambodia, Thailand, The Philippines, mosquito species), Ae. luteocephalus (an African mosquito
Peninsular Malaysia, and Borneo, and among travellers species), Ae. furcifer (an African mosquito species), Ae.
232 S.S.-Y. Wong et al.

vittatus (worldwide distribution), Ae. unilineatus (found in Clinical and laboratory aspects
Africa and parts of Asia, including India, Pakistan, and Saudi
Arabia), Ae. opok (an African mosquito species described in Clinically, Zika virus infection cannont be reliably differ-
Uganda), Ae. hensilli (endemic species in Micronesia, entiated from other arbovirus infections such as dengue
implicated in the outbreaks of dengue, chikungunya, and and chikungunya as the symptoms and signs are not
Zika virus infections in Yap Island of Micronesia), Ae. pathognomonic. The clinical and epidemiological features
aegypti, and Ae. albopictus.59,60,73e79 To most countries of are also confounded by co-circulation of different arbovi-
the world, the last two species, Ae. aegypti and Ae. albo- ruses in the same geographical area.60 Table 4 compares
pictus (nowadays more properly known as Stegomyia some of the features of dengue, Zika, and chikungunya.
aegypti and Stegomyia albopicta respectively),80 may pose After an incubation period of 3 to 12 days, Zika virus
the greatest threats, given their almost ubiquitous pres- infection presents initially with headache, a descending
ence in many tropical and subtropical countries, their maculopapular rash involving palms and soles (which can be
adaptation to the urban and peri-domestic environments, pruritic), fever, malaise, myalgia, anorexia, conjunctivitis,
their highly anthropophilic behaviours, invasion into some arthralgia, limb oedema and sometimes abdominal symp-
European and North American countries, and competence toms (abdominal pain, diarrhoea).50,105 Limb oedema and
to act as vectors for numerous other arboviruses.81 Ae. conjunctivitis appeared to be commoner with Zika virus
aegypti, in particular, is considered to be the prime vector infections than dengue or chikungunya, while hepatomeg-
for the transmission of Zika virus among humans. Ae. aly, leukopenia, and thrombocytopenia were less common
aegypti and Ae. polynesiensis are suspected to be the in Zika virus infections.105 During the Yap outbreak, the
vectors involved in the French Polynesian outbreak.82,83 In main clinical manifestation (incidence in parentheses) were
additon, Zika virus has also been isolated from other non- maculopapular rash (90%), fever (65%), arthritis/arthralgia
Aedes genera of mosquitoes including Mansonia uniformis, (65%), conjunctivitis (55%), myalgia (48%), headache (45%),
Culex perfuscus, and Anopheles coustani.84 However, it retro-orbital pain (39%), oedema (19%), and vomiting
must be remembered that the ability to isolate the virus (10%).59 Serious complications due to Zika virus infection
from certain mosquito species and their in vitro compe- were rarely reported in the past. However, during the
tence to support viral replication does not mean that those French Polynesian outbreak, an increased incidence of
species are necessarily important vectors epidemiologi- Guillain-Barré syndrome was noted, with an incidence that
cally. As in the case of other vectorborne infections, the is 20 times higher during the outbreak than non-outbreak
vectorial capacity depends not only on vector competence, periods.83,115 An association with Guillain-Barré syndrome
but also on the local density of the vectors, their host biting was also noted in the Latin American epidemic since 2015.
preference, feeding frequency, longevity (which is relevant In Brazil, 62% of the Guillain-Barré syndrome patients dur-
to the extrinsic incubation period of the arbovirus), and ing the outbreak had preceding symptoms consistent with
level of viral replication in the vectors.85e87 Zika virus infection.63 Death from Zika virus infection in
In addition to mosquitoes, other routes of transmission adults is rare but has been reported, although the exact
of Zika virus are possible, although these are unlikely to be contribution of the infection to mortality has not been
of major epidemiological significance under natural cir- detailed at the moment.116 The duration of immunity after
cumstances. Direct transmission from primates to human recovery from Zika virus infection is unknown. Co-infection
via animal bites has been suggested though not proven.88 with other arboviruses is possible, since the key Aedes
Coincidentally, Zika virus has also been detected in the vectors are capable of transmitting other arboviruses.117
saliva of 19.2% of infected individuals but the epidemio- The most striking and unexpected sequel of Zika virus
logical significance of this remains to be determined.89 infection is the possible association with congenital ab-
Sexual transmission has been documented, and the virus normalities, in particular, microcephaly. In some cases,
has been detected in the semen up to 62 days after onset of intrauterine or neonatal death may ensue.116 The epide-
febrile illness.90e92 Likewise, perinatal and congenital in- miological linkage was first observed in Brazil in 2015,
fections can occur.42,93 Another major clinical and public where the number of infants born with microcephaly
health concern is the potential for transmission through increased 20 times after the onset of the epidemic, with
transfusion and transplantation. In endemic countries, the over 1200 cases being reported in 2015 (99$7 per 100,000
proportion of asymptomatic or subclincial flaviviral in- livebirths).118 As of 30 January 2016, there were 4,783 cases
fections far exceeds the clinically overt cases. For of congenital central nervous system malformations recor-
example, the ratios between asymptomatic or inapparent ded in Brazil (compared to an annual incidence of 163
to clinical cases of dengue, Japanese encephalitis, and microcephaly cases in 2001e2014) with 76 deaths.63 In
yellow fever are 3e18:1, 250:1, and 7e12:1 addition to microcephaly, affected foetuses and infants
respectively.94e96 Detection of arboviruses in donated also have cerebral calcification seen in imaging.119,120 In
blood and their transmission through transfusion have been microcephalic infants, retinal abnormalities manifesting as
well documented for arboviruses such as dengue, West Nile, macular neuroretinal atrophy, macular pigment mottling,
and tick-borne encephalitis viruses, with concerns over foveal reflex loss, and chorioretinal atrophy, as well as
other viruses such as chikungunya and Ross River optic nerve hypoplasia were also observed.118,120 Ophthal-
viruses.97e103 During the French Polynesian Zika outbreak in mological examination of the infected mothers was uni-
2013e2014, 3% of asymptomatic blood donors were found formly normal.
to be viraemic using RT-PCR screening, thereby under- The management of pregnant women with Zika virus
scoring the potential for transfusion transmission of Zika infection remains problematic. The main difficulties
virus.104
Zika virus infection 233

Table 4 Epidemiological and clinical features of dengue, Zika, and chikungunya virus infections.59,61,105e114
Dengue virus Zika virus Chikungunya virus
Virology
Family Flaviviridae Flaviviridae Togaviridae
Nucleic acid Single-strand, positive sense, Single-strand, positive Single-strand, positive sense, RNA.
RNA. sense, RNA.
Main divisions 4 serotypes (1 to 4) 2 lineages (African 4 major lineages (West African,
and Asian) East/Central/South African [ECSA],
Indian Ocean, Asian)
Epidemiology
Natural Primates (sylvatic cycle). Primates (sylvatic cycle). Primates (sylvatic cycle).
reservoir
Key vectors Aedes mosquitoes. Aedes mosquitoes. Aedes mosquitoes.
for natural Sylvatic cycle: Ae. furcifer, Ae. Sylvatic cycle: Ae. africanus, Sylvatic cycle: Ae. africanus, Ae.
transmission luteocephalus, Ae. vittatus, Ae. furcifer, Ae. luteocephalus, furcifer, Ae. luteocephalus, Ae.
Ae. taylori, Ae. niveus. Ae. vittatus, Ae. unilineatus, neoafricanus, Ae. taylori, Ae.
Urban cycle: Ae. aegypti and Ae. opok. dalzieli, Ae. vigilax, Ae.
Ae. albopictus, other locally Urban cycle: Ae. aegypti, camptorhynchites, Ae. fulgens.
predominant species implicated Ae. albopictus; other locally Possibly Mansonia spp. as well.
(e.g. Ae. polynesiensis, predominant species implicated Urban cycle: Ae. aegypti, Ae.
Ae. pseudoscutellaris, (e.g. Ae. hensilli, Ae. albopictus.
Ae. malayensis, Ae. cooki). polynesiensis).
Endemic areas Tropics and subtropic areas. Asia: Cambodia, Indonesia, Widespread in sub-Saharan Africa,
Widespread in Asia, Africa, Malaysia, Pakistan, The Asia, Latin America, Pacific islands,
Latin America, Pacific islands, Philippines, Thailand. Indian Ocean islands.c
northeast Australia. Increasing Pacific islands: Micronesia, Europe: local transmission in
cases reported in southwestern French Polynesia, New northern Italy (2007) and southern
and southeastern United States.a Caledonia, The Cook Islands. France (2014) following
Africa: Senegal, Uganda, importation of the virus.
Nigeria, Côte d’Ivoire, Gabon,
Tanzania, Egypt, Central
African Republic, Sierra Leone.
Latin America: since 2015.b
Iatrogenic Transfusion-transsmission One case of transfusion- Transfusion-transmission
transmission confirmed; possibly transmitted infection declared potentially possible.
renal transplantation. by Brazilian authorities.d
Vertical Yes. No congenital Yes. Possible association with Yes. Possible centro-facial
infections abnormalities reported. microcephaly and maculopathy. hyperpigmentation.
Sexual Not reported. Yes. Not reported.
transmission
Clinical features
Incubation 3e10 days (usually 5e7 days). 2e12 days (usually 2e7 days). 2e6 days.
period
Duration of 2e3 days before to 4e5 Usually 3e5 days after onset About 6 days after onset of
viraemia days (range: 2e12 days) of symptoms (possibly over symptoms (range: 3e10) days.
after onset of symptoms. 11 days in some cases). Duration
of viraemia prior to disease
onset unknown.
Asymptomatic 14% in adults, 53% in children. 80%. 3e37%.
infection Over 75% in
some series.
Common clinical Fever, headache, retro-orbital Fever, headache, conjunctivitis, Fever, rash, myalgia, polyarthralgia,
manifestations pain, maculopapular rash or itchy maculopapular rash, polyarthritis, diarrhoea, vomiting,
“white islands in a sea of red”, arthralgia (small joints of hands abdominal pain.
arthralgia, myalgia. and feet), oedema of
extremities, oral ulcers.
(continued on next page)
234 S.S.-Y. Wong et al.

Table 4 (continued )
Dengue virus Zika virus Chikungunya virus
Uncommon Severe dengue: vascular leakage, Guillain-Barré syndrome, Conjunctivitis, uveitis, iridocyclitis,
or severe haemoconcentration, bleeding encephalitis, meningoencephalitis. retinitis, meningoencephalitis,
manifestations diathesis, shock, end organ Possible congenital infection myocarditis, hepatitis, multi-organ
involvement (previously leading to microcephaly and failure.
referred to as dengue maculopathy.
haemorrhagic fever and
dengue shock syndrome)
Case-fatality Less than 1% to 5% with dengue Very low. 0.1%.
ratio fever. Severe dengue without
adequate treatment, up to 20%
or above, but can be reduced to
less than 1% with proper
management.
Key laboratory Leukopenia, lymphopenia, Relatively normal blood tests. Leukopenia, lymphopenia,
findings thrombocytopenia, Occasional mild thrombocytopenia, thrombocytopenia, hypocalcaemia,
elevated transaminases. leukopenia with monocytosis elevated transaminases.
Haemoconcentration reported.
(increased haematocrit) and
coagulation abnormalities in
severe dengue.
Diagnostic tests NS1 antigen detection, RT-PCR, RT-PCR, antibody detection RT-PCR, antibody detection.
of choice antibody detection. (ELISA and neutralization assay).
Antiviral None. None. None.
therapy
Vaccine Vaccine first marketed in 2015. None. None.
prevention
a
Updated map of countries with dengue transmission can be found at http://www.healthmap.org/dengue/en/.
b
Updated map of American countries with autochthonous Zika virus transmission during the 2015 outbreak can be found at Regional
Office for the Americas of the World Health Organization, http://www.paho.org/hq/index.php?optionZcom_content&viewZ
article&idZ11669&ItemidZ41716&langZen.
c
Updated map of countries with chikungunya transmission can be found at http://www.cdc.gov/chikungunya/geo/.
d
Quoted by the Center for Infectious Disease Research and Policy, The University of Minnesota, on 4 February 2016. No official sci-
entific publications are available at the time of writing. Available at: http://www.cidrap.umn.edu/news-perspective/2016/02/brazil-
confirms-blood-transfusion-zika-paho-calls-global-support. [accessed 18.02.16.].

include the uncertainty of the risk of developing congenital suckling mice.123 While these are useful for virological
abnormalities after infection of the pregnant women, the studies and research, they are impractical for most clinical
risk associated with infection at different time of gestation, laboratories. Laboratory-acquired infections of Zika virus
and the lack of alternative antenatal diagnostics other than have also been reported.50 Zika virus is classified as a
imaging studies. Current guidelines generally recommend biosafety level 2 organism according to the US CDC and
monitoring of pregnant women with a recent travel history human pathogen hazard group 3 according to the UK Advi-
to endemic areas, early diagnosis of infection, close ante- sory Committee on Dangerous Pathogens.124,125 Antibody
natal and postnatal surveillance and monitoring of infected detection and nucleic acid amplification using RT-PCR are
women, exclusion of other congenital infections (such as the usual diagnostic tests of choice. A commercial system
toxoplasmosis, cytomegalovirus infection, rubella), amnio- (EUROIMMUN AG, Lübeck, Germany) detecting anti-Zika IgG
centesis for virological investigations if radiological abnor- and IgM using ELISA (with recombinant NS1 antigen) and
malities are detected, and consideration of termination of indirect immunofluorescence assay (which also allows dif-
pregnancy after thorough counselling of the pregnant ferentiation between Zika, chikungunya, and dengue vi-
women.116,121,122 Zika virus can be detected by RT-PCR in ruses) was marketed in January 2016. An in-house ELISA
the amniotic fluid of microcephalic foetuses, but the posi- antibody test was developed during the Yap outbreak by
tive and negative predictive values of the RT-PCR finding the Centers for Disease Control and Prevention, USA. As
(either in the amniotic fluid or even chorionic villus sam- expected, IgG and IgM antibody testing using ELISA shows
pling) for the development of congenital abnormalities are cross-reaction with other flaviviruses, especially in patients
unknown, and the test has not been well evaluated for with prior flaviviral infections. IgM antibodies are detect-
specimens other than blood.93,116,122 able from days 3e8 after onset of illness. Antibody testing
Zika virus can be cultured in a number cell lines such as by the plaque reduction neutralization test is more spe-
Vero and LLC-MK2, or by intracerebral inoculation of cific.44 In-house indirect immunofluorescent assays have
Zika virus infection 235

also been described for antibody detection.126 Although molecules against non-structural proteins (especially NS3
antibody testing suffers from cross reactivities with other and NS5 proteins) are ongoing.136e138 A few currently
flaviviruses, it remains an essential diagnostic means, available drugs such as the tetracyclines, chloroquine,
especially in patients who presented late in the course of amodiaquine, and mefenamic acid have shown in vitro
disease where RT-PCR tests could be negative (about inhibitory acitivities against flavivirus (mostly with dengue
5e7 days after onset of disease).126 The usual laboratory virus), but it is still too early to comment on their potential
test of choice for acute Zika virus infections is RT-PCR on clinical benefits.139e144
clinical samples, most commonly the peripheral blood. RT-
PCR allows accurate differentiation of Zika virus from other
pathogens which may share similar clinical manifestations, Prevention
and this is especially useful in areas where co-circulaion of
different arboviruses is prevalent. Genotyping of the viral Pregnant women are discouraged from travelling to Zika-
strains is also possible. In the Yap outbreak, one third of the endemic areas.145 In addition to bite avoidance measures,
sera collected within 10 days after disease onset were still non-pregnant, sexually active women of reproductive age
positive by RT-PCR.59 PCR protocols have been developed residing in endemic areas should consider the issues of
using primers directed towards various targets including E, family planning and contraception, taking into account
NS5, and prM/E, and M.44,51,127e129 Duration of viraemia in various social and religious precepts.122 At present, the only
humans ranges from 1 to more than 11 days after the onset flaviviral vaccines available for human use are yellow fever
of disease.50 The viral load in patient sera appears to be (live attenuated), Japanese encephalitis (inactivated, live
relatively low, ranging from 930 to 728,800 (median: attenuated, and chimeric), tick-borne encephalitis (inac-
21,495) copies/mL in a series of 17 patients in the Yap tivated) vaccines, and the newly marketed dengue vaccine
outbreak in 2007 (sera were mostly collected within 3 days (live attenuated, recombinant, tetravalent; marketed since
after onset of disease).44 One patient in that study had a 2015). Claims were made by an Indian biotechnology com-
viral load of 338,797 copies/mL when the blood was pany that two Zika virus vaccine candidates (recombinant
collected on day 11 after disease onset. Zika virus RNA has and inactivated) can be tested soon; however, no details on
also been detected in the saliva, urine, and semen of some the vaccine preparations are currently available in the
patients; remarkably, the positive rate of RT-PCR in saliva is scientific literature.146 In any case, a normal vaccine
higher than that of blood (57.1% vs. 28.1%).89,91,130 The development cycle usually requires years of preclinical and
additional value of performing RT-PCR on urine and saliva clinical studies and a Zika virus vaccine for human use is
over blood, other than the ease of specimen collection, is unlikely to be available in the near future.
unknown because the viral kinetics in these body fluids In the absence of vaccines or chemoprophylaxis, the
have not been determined. prevention of Zika virus infection follows the general rules
The NS1 antigen of dengue virus has revolutionized the for other vectorborne infections. Broadly speaking, this
laboratory diagnosis of dengue, providing a simple and involves two major areas, personal protection through bite
rapid point-of-care diagnostic means with high specificity avoidance and vector control. Bite avoidance is equally
and ability to diagnose the infection early in the course important to both residents in and travellers to endemic
(especially in the first 3 days after disease onset).131 areas. Personal protection includes general measures such
Although commercially available NS1-based diagnostic as protective clothings, proper choice and use of insect
technique is currently limited to dengue, this may poten- repellents, and mosquito-proofing of houses. The use of
tially be applicable to other flaviviral infections because insecticide-impregnated bednets has been one of the core
circulating NS1 antigens have also been detected in Japa- elements in the prevention and control vectorborne dis-
nese encephalitis and West Nile virus infections.132,133 No eases such as malaria in endemic countries. However, its
information on the detection of circulating NS1 antigen in role against the Aedes vectors of Zika virus depends on the
Zika virus infection is currently available. Caution should be behaviours of the vectors in specific geographical areas. In
excercised in the interpretation of dengue NS1 antigen general, Ae. aegypti mosquitoes are endophilic (resting
testing results, for false positive result has been reported in indoors), endophagous (biting indoors), anthropophagic
a patient with acute Zika virus infection and other under- (preferentially biting humans), and diurnal and crepuscular
lying diseases.134,135 in their activities. Ae. albopictus mosquitoes are generally
Treatment of Zika virus infection is primarily supportive. exophilic (resting outdoors), exophagous (biting indoors),
Nonsteroidal anti-inflammatory drugs should be avoided and anthropophilic, and are aggressive daytime
unless dengue has been excluded.116,122 Standard pre- biters.147e149 However, it is known that the endophilic/
cautions in health care settings are adequate, with addi- exophilic and endophagous/exophagous behaviours are not
tional measures in mosquito-proofing of the health care absolute and these can be variable in different geograph-
facilities. Insect repellents and mosquito bite avoidance ical areas.150 A thorough knowledge of the local mosquitoes
are recommended for health care workers looking after and their behaviours are therefore crucial to the control of
Zika patients.116 It would be prudent to recommend pa- vectorborne diseases, and this underlines the importance
tients in the first one to two weeks after the onset of illness of long-term local vector surveillance.
to adhere to bite avoidance measures in order to reduce The proper use of insect repellents is the keystone in
the risk of secondary transmission. No antivirals are personal protection against haematophagous arthropods. A
currently licensed for specific therapy against flaviviral in- number of insect repellents are widely available on the
fections (except hepatitis C virus), although in vitro studies market, each of which has different repellent efficacies
with therapeutic antibodies, small interfering RNA, and against different mosquito genera and other arthropods
236 S.S.-Y. Wong et al.

such as mites, tickes, and flies. Despite negative publicity preventive measures against other vectorborne infections
against it in recent years, N,N-diethyl-m-toluamide (DEET) should not be forgotten. These include the use of antima-
remains the gold standard in insect repellents against which larial chemoprophylaxis and yellow fever vaccination (as
other newer compounds are benchmarked. DEET was dictated by the destination) as appropriate, as there are
initially developed and patented by the US Army in 1946 overlaps in the current endemic areas of these infections
and commercialized since 1957. It is generally applied to and the possibility of further spread of Zika virus infection
skin in the form of liquids, aerosols, or lotions, and can be in the future.170 Vaccination against Japanese encephalitis
used to impregnate clothings if necessary (although and tick-borne encephalitis may be considered for travel-
permethrin is more commonly used for this purpose). lers to endemic areas with high-risk exposures, and dengue
Commercially available DEET formulations range from 4% to vaccination may potentially be considered in the future
100% in concentration. It is a common misconception that when more data are available.
higher concentrations provide “more powerful” protection Vector control is the only long-term solution to the
against arthropods. Higher concentrations merely prolong control of vectorborne diseases. During outbreak situations,
the duration of protection. At a concentration of 15%, DEET emergency measures such as the use of space spray
protects against Ae. aegypti and Ae. albopictus bites for (fogging) may be deployed to rapidly bring down the num-
about 7e8 hours.151 The effect plateaus at a concentration ber of biting adults and terminate disease transmission.
of about 50%. Although percutaneous absorption of DEET However, this is not a sustainable measure in the long run.
does occur, the level is extremely low as compared to the The details of mosquito control are beyond the scope of this
lethal doses observed in animals.152,153 DEET has an excel- article. In brief, this mainly involves source reduction by
lent record of safety and efficacy after 60 years of use. It is larval control. Ae. aegypti and Ae. albopictus are typical
not oncogenic, teratogenic, or genotoxic at maximum container-breeding species which thrive in urban and man-
tolerated doses in animals. Reports of serious human made environments. Unlike other mosquites which breed in
toxicity mainly relate to neurotoxicity, especially seizures open water areas, environmental management measures
in children. However, such reports remained rare (when are less likely to be effective. Raising the awareness of the
compared to the total number of individuals exposed to community and engaging citizens in source reduction in
DEET over the years) and in many of the reported cases, a households and their vicinity is the key to success in con-
definitive causal relationship between DEET and neurotox- trolling these mosquito species.171,172 Other means of
icity cannot be established (other than the few cases of mosquito control, some of which are still experimental or in
deliberate or accidental ingestion in huge quantities or the early phases of field trials, include the use of biological
improper use of the products).154e158 Similarly, although measures such as entomopathogenic fungi and genetic
detectable levels of DEET can be found in cord blood of measures including sterile insect techniques.172,173 Obvi-
infants born to mothers using DEET during second and third ously, all vector control strategies have to be continued as
trimesters of pregnancy, no adverse outcomes of pregnancy perennial exercises because various mosquito genera,
have been found in a double-blind, randomized trial.159 including Aedes spp., are capable of overwintering, and
Hence, when used appropriately according to recommen- that the eggs of Aedes mosquitoes are well known for their
dations, DEET is still considered to be safe in children older ability to withstand prolonged periods of desic-
than 2e6 months of age, as well as in pregnant and cation.174e176 Vector control measures must go hand in
lactating women.160e164 A DEET concentration of 20% to 30% hand with vector surveillance, not only to monitor the
is generally recommended for adult use. density of mosquitoes (which may sometimes be correlated
Effective and safe alternatives to DEET are available. with the risk of transmission), but also to detect coloniza-
The most commonly used ones are ethyl butylacetylami- tion by invasive species which may contribute to local
nopropionate (IR3535, more effective against Aedes and spread of the infection.177e179 The public health signifi-
Culex than Anopheles mosquitoes), picaridin (also known as cance of vector control and surveillance cannot be over-
icaridin; concentrations of 20% are needed), p-menthane- stated. Aedes mosquitoes, in particular, Ae. aegypti and
3,8-diol (PMD), and possibly 2-undecanone Ae. albopictus, are notorious for their vectorial capacity in
(BioUD).151,165,166 For impregnation of clothings, shoes, transmitting multiple vectorborne infections. Dengue, for
and other equipment, permethrin is generally preferred.158 example, has taken its toll in many continents. From 4
Various botanical compounds have been advocated as nat- January 2015 to 14 February 2016, 44,196 cases of dengue
ural and harmless insect repellents. These are often fever have been recorded in Taiwan, making it one of the
essential oils extracted from plants. While many of these biggest outbreaks of the disease on the island.180 Given the
oils do possess repellent activities, most of them are too fact that the competent vectors Ae. aegypti and Ae.
volatile to offer lasting protections (usually lasting for less albopictus are highly prevalent in many tropical and sub-
than 1 hour) and even these natural products may cause tropical countries, the potential for Zika virus to cause
adverse reactions, especially skin irritation.158,165,167e169 outbreaks, and worse, co-circulation with other arbovi-
Insect repellent-treated wristbands, garlic, oral vitamin B, ruses, in these areas is very high.181
and electronic buzzers (which claim to produce ultrasound The role of border screening in preventing the impor-
to repel insects) are completely ineffective as bite avoid- tation of infectious diseases has previously been dis-
ance measures.165,169 Whichever insect repellent is chosen, cussed.182 Although this is deployed in many countries
one must beware of potential limitations, such as repeating (especially among Asian countries), border screening
the application after heavy sweating, swimming, or raining, cannot reliably detect all infected individuals because of
and applying the repellent about 20 minutes after the the asymptomatic incubation period. In the prevention of
application of sunscreens. For international travellers, Zika virus infection, perhaps a more realistic approach is to
Zika virus infection 237

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