For posterity...and citations

This is happening quickly, so let's discuss all these happenings on a later date. Brief summary, I'd like to document this, for my own protection. As they often say in the real world, cover yo assss.

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Flying Needles of the World: An Update on Zika Virus

In my mind, mosquitoes are the terrifying, flying dirty needles of the world. One bite from one little bloodsucker enters you into a game of roulette and you’ll soon find yourself on a wheel, careening wildly past unfortunate options like dengue, chikungunya or malaria. Best case scenario, you’ll win some general itchiness. Fortunately, for us living here in the United States, our minds rest easy knowing that the risks of catching any mosquito-borne disease are slim. Here we hide, safely ensconced in air-conditioned spaces, shielded from the outside world by window screens. We travel through streets lacking large pools of standing water, the beloved nests of mosquito larvae, and when the threat of being bitten is imminent, we liberally spray plumes of OFF! ® and mosquito repellant.

Yet, recently, our mosquito concerns have amplified. On May 31, 2016, a child was born in a New Jersey hospital with Zika virus-related microcephaly (1). This child’s birth marks the very first Zika-related birth defect on the mainland of the United States, preceded only by another baby born in Hawaii earlier this year. I suppose it’s time to say it. “Welcome to the US East Coast, Zika,” or rather, “Hello, potential epidemic.”

Zika virus is a flavivirus transmitted by the Aedes mosquito (species stegmoyia, aegypti, albopictus), which populates some of the eastern US states, majority of the southeastern US states, and all countries below and across the Atlantic. The virus was identified long ago in 1947 in Uganda, but prior to 2007, had only been seen sporadically throughout Asia and Africa. Zika’s rapid travel across oceans to the Americas is a very recent occurrence and it was only in February 2016 that the World Health Organization declared Zika a public health emergency (2).

For your edification, let’s just talk about some of the more horrifying aspects of this virus. Zika is an entirely different beast than malaria and targets specific subpopulations: primarily pregnant women, their infants/children and residents of landfill area or areas of abandoned housing (high prevalence of standing water). The virus induces microcephaly or congenital brain abnormalities in infants of pregnant, infected women and is also associated with increased incidence of Guillain-Barré syndrome. As of May 12, 2016, there have been 279 reports of pregnant women residing in US states, the District of Columbia, and US territories with laboratory-confirmed evidence of possible Zika infection (3).

The Center for Disease Control and Prevention (CDC) has thus mobilized in full force against Zika. I was fortunate enough to attend a presentation on June 1, 2016, by Chris S. Kochtitzky, MSP, the Associate Director for Program Development/Public Health Advisor for the Division of Emergency and Environmental Health Services, a division of the CDC. In his talk, he detailed the CDC’s top priorities and multifactorial approach, in which vector control plays the primary role. Using an integrated pest management strategy, the CDC believes that stringent control of mosquito populations through management of cultural factors like sanitation, use of physical/mechanical barriers, and application of biological and chemical agents (larvicides and insecticides) will lead to successful prevention of spread (4). Other top priorities are public health surveillance and laboratory testing support for infected individuals.

You may ask, “What can I personally do?” Zika virus does not have any oral manifestations, and so, as dentists, our work with the virus is rather limited. Of course, it’s certainly possible that a patient could present with fever, rash, arthralgia, and conjunctivitis, the hallmarks of Zika and tell you that he or she has been in or slept with someone from a high-risk Zika virus area...but come on, let’s be realistic here. What is more likely to occur is that you contract Zika during a summer trip to South and Central America, Mexico, the Pacific Islands, the Caribbean, or Africa. Consequently, to do your part in prevention, the CDC recommends traveling prepared and avoiding bites. Pack a “Zika Prevention Kit,” consisting of a bed net, insect repellant, permethrin spray, standing water treatment tabs, and condoms. Condoms?! On April 15, 2016, the CDC reported a total of 6 cases of sexually-transmitted Zika virus infection in published literature, with five male-to-female transmissions and one case of male-to-male transmission (5). Fortunately, while Zika can be transmitted sexually through infected semen and saliva, the risk of transmission via this route is difficult to quantify and studies are still ongoing (6). Either way, better safe than sorry.

What is perhaps more important is to avoid being bitten and know when you are infected. Current diagnostic laboratory tests are limited and the virus is sneaky. While studies have shown that Zika virus RNA can be quantified in urine, serum, saliva, and semen using real time reverse-transcription polymerase chain reaction, approximately 80% of infected patients are asymptomatic and infectious during the first 6-8 days post infection (7). You may not make it to a laboratory in time to even realize you’ve been bitten! So, dear dental student, if you do happen to travel to a high-risk area this summer, get bitten, and fall ill, I implore you. Please see your doctor and avoid getting more mosquito bites during your first week of illness. If you are unwittingly infectious, you can pass the Zika virus from your blood to another through mosquitoes. Flying, dirty needles of the world, am I right?

References

1. Goldschmidt Debra. Baby with Zika-related microcephaly born at New Jersey hospital. CNN News. June 1 2016. http://www.cnn.com/2016/06/01/health/baby-born-microcephaly-new-jersey/. Accessed June 2 2016.

2. The Centers for Disease Control and Prevention. Zika Virus. http://www.cdc.gov/zika/index.html. Reviewed February 11, 2016. Updated May 20, 2016. Accessed 23 May 2016.

3. Simeone RM, Shapiro-Mendoza CK, Meaney-Delman D, et al. Possible Zika Virus Infection Among Pregnant Women – United States and Territories. May 2016. MMWR Morb Mortal Wkly Rep 2016;65. DOI: http://dx.doi.org/10.15585/mmwr.mm6520e1.

4. Kochtitzky, Chris S. Presentation: An Evolving Environmental Health Services Role in the Zika Response at the 2016 CDC Undergraduate Public Health Scholars and Dr. James A. Ferguson Emergeing Infectious Diseases Fellowship; June 1, 2016; Atlanta GA. 

5. Deckard DT, Chung WM, Brooks JT, et al. Male-to-Male Sexual Transmission of Zika Virus — Texas, January 2016. MMWR Morb Mortal Wkly Rep 2016;65:372–374. DOI: http://dx.doi.org/10.15585/mmwr.mm6514a3.

6. Liuzzi G, Nicastri E, Puro V, Zumla A, et al. Zika virus in saliva-New challenges for prevention of human to human transmission [published ahead of print 11 May 2016]. Eur J Intern Med. doi: 10.1016/j.ejim.2016.04.022.

7. Bingham AM, Cone M, Mock V, et al. Comparison of Test Results for Zika Virus RNA in Urine, Serum, and Saliva Specimens from Persons with Travel-Associated Zika Virus Disease — Florida, 2016. MMWR Morb Mortal Wkly Rep 2016;65. DOI:http://dx.doi.org/10.15585/mmwr.mm6518e2

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And of course, we need to end on a recipe. These suckers get crunchy after a few days, so eat them fresh.

Crispy Chewy Granola Bars

8-10 bars

2 C rice puffs

1 C thick rolled oats

1/2 C wheat germ

1/4 C flax seeds

1/3 C honey

2-3 TB blackstrap molasses

3 TB peanut butter

1/2 C dark brown sugar

pinch of salt

mix-ins*

1/3 C dried blueberries

1/3 unsweetened coconut flakes

1/3 C roughly chopped pecans

*Note: mix-ins should equal 1 C

Preheat the oven to 300 degrees. In a large bowl, mix together the rice puffs, rolled oats, wheat germ, and flax seeds. Mix in the  the 1 C of mix-ins at this point. On the stove, melt together the honey, molasses, peanut  butter, dark brown sugar, and salt until a caramel-like sauce is formed (no need to bring to a boil). Let cool briefly, then pour over your dry ingredients and mix it all together until a stikcly mixture is formed. 

Transfer the mixture to parchment paper on a large cookie or baking sheet, Using plastic wrap (oiled hands, spatulas, whatever you prefer), press the mixture into the shape of fat granola bars, compacting the granola. Bake for 12-15 minutes, until the sugar is bubbling a bit, then remove bars and let cool. Be careful not to overbake or they will become crunchy, rather than have an intense, chewy texture.