Preparedness for Zika Virus Disease — New York City, 2016

The rapid spread of Zika virus across the World Health Organization’s Region of the Americas has had a direct effect on the U.S. health care delivery system. Hospitals in New York City (NYC) have been implementing prevention and response efforts consistent with CDC guidance. As of September 21, 2016, a total of 715 cases of laboratory-confirmed Zika virus disease had been diagnosed in New York state among travelers who returned from affected areas, their sexual contacts, or infants infected in utero. This represents the highest number of reported cases in any state to date, and underscores the importance of health care systems preparing to care for patients with possible Zika virus disease (1). Building upon a framework that was established in 2014 to screen patients for possible exposure to Ebola virus disease (Ebola), NYC Health + Hospitals,* the largest municipal health care delivery system in the United States, implemented a Zika Preparedness and Response Action Plan^† (Zika Action Plan) to address the threat from Zika and ensure appropriate patient care. The plan developed by NYC Health + Hospitals includes universal travel screening, signage depicting areas with active Zika virus transmission, clinical and epidemiologic evaluation for possible Zika virus exposure, diagnostic testing for Zika virus infection and linking of infected patients to appropriate specialists, and education on Zika virus disease and preventive measures (e.g., avoiding travel to areas with active Zika virus transmission).

NYC Health + Hospitals operates an integrated health care system that includes 11 acute care hospitals, six of which are regional trauma centers, six long-term care centers, numerous community-based health centers, a correctional health services unit, and a home care agency. The 42,000 staff members of NYC Health + Hospitals serve a population of approximately 1.2 million; the obstetrical units perform >18,000 deliveries each year.^§ To prepare for and manage the Zika virus threat, NYC Health + Hospitals built its Zika Action Plan from a framework established during the 2014 Ebola outbreak. The Zika Action Plan is closely coordinated internally with its integrated system of hospitals and externally with the New York City Department of Health and Mental Hygiene (DOHMH) and the New York State Department of Health. Existing general protocols, such as universal screening for recent travel and exposure to communicable diseases, were augmented to include surveillance information about areas with local transmission of Zika virus to enhance early recognition and management of persons with Zika virus infection. The Zika Action Plan, which details the criteria for testing and reporting of Zika virus disease, includes Zika virus screening algorithms for pregnant and nonpregnant females, adult males, children, and newborns, and is based on guidance from CDC and DOHMH practices. Objectives of the Zika Action Plan include rapidly identifying patients at risk for Zika virus infection, offering testing, and providing all necessary care and counseling to persons with confirmed or probable Zika virus infection (2–4). The Zika Action Plan has been distributed across the NYC Health + Hospitals system of hospitals and ambulatory care centers and placed on the system’s internal intranet site for easy access.

Initial screening for possible Zika virus infection at all points of entry into NYC Health + Hospitals emergency departments, ambulatory units, and obstetrical settings includes signage that depicts areas with active Zika virus transmission. The signage is continually updated based on CDC guidance, and as new countries are added to the list of those with active transmission. A Zika-specific job aid (Figure 1) prompts personnel at the point of entry with a set of initial screening questions regarding travel history of the patient and the patient’s sexual contacts and any signs or symptoms compatible with Zika virus disease. Although local mosquito-borne transmission of Zika virus has not been documented, NYC Health + Hospitals personnel are encouraged to be vigilant for patients with Zika-compatible symptoms even in the absence of travel or sexual exposure risk (5). The Zika-specific job aid also references the NYC Health + Hospitals Zika Virus Pregnancy Screening Protocol (Figure 2). If a patient is pregnant, the greeter is prompted to refer her to the pregnancy screening protocol immediately for next steps.

The Zika Action Plan instructs clinicians to test for Zika virus disease after identifying a patient meeting the CDC case definition for suspected Zika virus disease^¶ (6). Information is solicited about travel to an area with ongoing Zika virus transmission or sexual contact with a person who traveled from such an area; receipt of blood, blood products, or an organ transplant within 30 days of symptom onset; and other potential epidemiologic links to a confirmed or probable case of Zika virus disease, including suspected mosquito-borne transmission and any other unusual clinical manifestation or suspected route of exposure (6,7). Laboratory testing, if indicated, can be performed at DOHMH or at a specified commercial laboratory. Patient specimens from travel-associated cases of suspected Zika virus infection are sent to the commercial laboratory for testing and do not require the clinician to call DOHMH. Clinicians are instructed to call DOHMH for testing in all nontravel-associated cases of suspected Zika virus disease.

The NYC Health + Hospitals electronic health system also has built-in algorithms to prompt for Zika virus testing if relevant travel history and pregnancy status is entered. The laboratory management section of NYC Health + Hospitals Zika Action Plan discusses consideration of obtaining laboratory studies for alternative diagnoses, including chikungunya and dengue virus infection, when appropriate and consistent with current guidance (8). Nonpregnant patients with possible Zika virus exposure who do not meet clinical criteria for Zika virus testing (i.e., lack symptoms of Zika virus infection) are offered counseling to limit potential spread of Zika virus.

Zika preparedness and response efforts of NYC Health + Hospitals include hosting a series of internal, system-wide electronic town hall meetings. These events are open to all 42,000 staff members of NYC Health + Hospitals. A Zika-specific e-mail address also has been created for staff members to submit ongoing Zika-related questions or concerns. This Zika-specific e-mail address is monitored continually by NYC Health + Hospitals, Emergency Management, and questions are answered within 24 hours by clinical leaders. To assess staff competency and appropriate screening and identification of suspected cases of Zika virus infection, NYC Health + Hospitals, Simulation Center and Emergency Management is conducting a series of no-notice simulation exercises at each of the system’s prenatal clinics. Scenarios include a pregnant woman and accompanying partner with Zika-compatible risk factors. The goal of these exercises is to assess each clinic’s ability to screen for, identify, offer testing for, and provide education on Zika virus infection, including modes of transmission and ways to prevent the spread of Zika virus, and then provide corrective actions as necessary when deficiencies are identified (e.g., directing the prenatal clinic leadership to the NYC Health + Hospitals Zika intranet page for the most up-to-date Zika guidance and information).

During April–July 2016, a total of 729 patients from NYC Health + Hospitals were tested for possible Zika virus infection.** Testing for Zika virus infection increased substantially over the 4-month period, with 29 tests in April, 69 in May, 314 in June, and 317 in July. Since mid-July, NYC Health + Hospitals has been sending specimens from nonpregnant persons with noncritical, travel-related cases of potential Zika virus infection to a commercial laboratory for testing. All other specimens for Zika virus testing are sent to DOHMH.

As the number of laboratory-confirmed Zika virus disease cases continues to rise, health care systems should be vigilant and prepared to address this public health concern. Close collaboration with state and city health departments will play a critical role. The program implemented by NYC Health + Hospitals can serve as a guide for other health care systems to screen patients and offer Zika virus testing, and to link patients with laboratory-confirmed infection to appropriate care.

Corresponding author: Syra Madad, syra.madad@nychhc.org, 212-323-2521.

¹New York City Health + Hospitals, Emergency Management; ²New York City Health + Hospitals/Elmhurst; ³New York City Health + Hospitals, Central Office.

References

1. CDC. Zika virus: case counts in the US. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. http://www.cdc.gov/zika/geo/united-states.html
2. Oduyebo T, Igbinosa I, Petersen EE, et al. Update: interim guidance for health care providers caring for pregnant women with possible Zika virus exposure—United States, July 2016. MMWR Morb Mortal Wkly Rep 2016;65:739–44. . CrossRef PubMed
3. Russell K, Oliver SE, Lewis L, et al. Update: interim guidance for the evaluation and management of infants with possible congenital Zika virus infection—United States, August 2016. MMWR Morb Mortal Wkly Rep 2016;65:870–8. . CrossRef PubMed
4. Petersen EE, Meaney-Delman D, Neblett-Fanfair R, et al. Update: interim guidance for preconception counseling and prevention of sexual transmission of Zika virus for persons with possible Zika virus exposure—United States, September 2016. MMWR Morb Mortal Wkly Rep 2016;65:1077–81. CrossRef PubMed
5. New York City Department of Health and Mental Hygiene. 2016 health alert #28: detecting Zika virus transmission in New York City. New York, NY: New York City Department of Health and Mental Hygiene; 2016. https://www1.nyc.gov/assets/doh/downloads/pdf/cd/zika-advisory28.pdf
6. CDC. Zika virus disease and Zika virus, congenital infection 2016 case definition. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://wwwn.cdc.gov/nndss/conditions/zika-virus-disease-and-zika-virus-congenital-infection/case-definition/2016/
7. New York City Department of Health and Mental Hygiene. Zika virus: information for providers. New York, NY: New York City Department of Health and Mental Hygiene; 2016. http://www1.nyc.gov/site/doh/providers/reporting-and-services.page
8. CDC. Guidance for U.S. laboratories testing for Zika virus infection. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. http://www.cdc.gov/zika/laboratories/lab-guidance.html

FIGURE 1. Zika-specific job aid that prompts health care providers with a set of initial screening questions — NYC Health + Hospitals, 2016

FIGURE 2. Zika-specific job aid that references Zika virus pregnancy screening protocol — NYC Health + Hospitals, 2016