Causing an epidemic affecting almost 2 million individuals... in 2015. Causing an epidemic affecting almost 2 million individuals, the Zika virus was officially declared a global health emergency by WHO (2016c) following an outbreak detected in Brazil in 2015. As of February 1, 2016, Zika virus had emerged in 25 countries and territories in South or Central America, with alarming reports of microcephaly cases among neonates in Brazil (Cao-Lormeau et al., 2016). Reports linking Zika with microcephaly and foetal deaths in the Americas, and with serious neurological disease, particularly Guillain-Barre syndrome (GBS), led to the WHO declaration (2016c).

Thus Zika virus has emerged as a health issue of public importance. Given the increase in congenital anomalies and other neurological and autoimmune syndromes, the Pan American Health Organization/World Health Organization (PAHO/WHO) has made recommendations for healthcare facilities related to strengthening capacity and specialized care. Effective strategies to prevent and control the virus, such as mosquito vector control and education of the public, are encouraged (Yakob & Walker, 2016; WHO 2016d).

Many nurses hold lead positions in health education, health promotion, and health surveillance to identify, prevent, and manage Zika virus. This review examined public health issues emerging in areas affected by Zika virus to identify potential strategies that nurses could employ in the effort to diminish its impact. We explored current literature about both Zika virus and nurse roles in epidemics, other infectious disease prevention, and health promotion to identify known issues and recommendations. This article reports on what is currently known about Zika virus and discusses public health issues and how nurses may address health concerns.

Zika History

First isolated in 1947, Zika virus (ZIKV; genus Flavivirus, family Flaviviridae) is an emerging globally mosquito-borne pathogen of growing public health importance (Diagne et al., 2015). The first well-documented report of human ZIKV infection was in Uganda in 1964 when a scientist described his own occupationally acquired illness (Simpson, 1964). Subsequently, Zika has been recognized as a cause of febrile illness in humans in Africa and Southeast Asia, with symptoms that include fever, headache, conjunctivitis, myalgia, rash, and joint pains (Duffy et al., 2009; Hayes, 2009; Karabatsos, 1985).

...the disease has now been linked to neurological disease and foetal abnormalities. Although also known in Malaysia (1966), human Zika virus disease with clinical presentations was uncommon until an epidemic was identified on the Micronesian island of Yap in 2007. It then spread across the Pacific to Easter Island and in 2015–16, it emerged in South and Central America and the Caribbean (Lancet, 2016) Before the French Polynesian outbreak, Zika virus infection was described as a mild febrile illness, but with its release in Brazil, the disease has now been linked to neurological disease and foetal abnormalities (Cao-Lormeau et al., 2016).

Clinical Manifestation

The incubation period of Zika virus disease is not clear, but is probably a few days. Symptoms include fever, skin rashes, conjunctivitis, muscle and joint pain, malaise, and headache. These symptoms are usually mild and last for 2 to 7 days (WHO, 2016d). Although symptoms of Zika virus disease are similar to other arbovirus infections such as dengue, there are notable differences worthy of concern (Kelser, 2016). Table 1 provides a comparison of symptoms between Zika and Dengue viruses.

Table 1: Symptom Comparison: Zika and Dengue Viruses

Transmission of Zika Virus

Similar to most arboviruses, Zika virus develops mainly in tropical or sub-tropical areas. Transmission of Zika virus includes an arthropod-borne vector and a vertebrate host. Similar to most arboviruses, Zika virus develops mainly in tropical or sub-tropical areas. The virus is primarily transmitted by female mosquitos that feed on vertebrate blood. The lifespan of a female mosquito is 1 to 2 months; female mosquitoes have to be transmission competent for the life cycle of the arbovirus to be complete (WHO, 2016d).

Mosquito Transmission
Zika virus is transmitted to people via a bite from an infected mosquito from the Aedes genus, mainly Aedes aegypti in tropical regions. This mosquito also transmits chikungunya, dengue, and yellow fever (WHO, 2016d). Numbers of this mosquito can rapidly spread in small amounts of water and they are known to be most aggressive during daytime. Originally, this mosquito was found in Africa; now it is found in all subtropical and tropical climate areas (Chang, Ortiz, Ansari, & Gershwin, 2016).

Non-Mosquito Transmission
Although Aedes mosquito bites are mainly responsible for transmission of Zika virus, recent reports have indicated other causes of transmission including sexual intercourse, perinatal transfer, and blood transfusion (Besnard, Lastere, Teissier, Cao-Lormeau, & Musso, 2014). In 2014, an investigation of Zika virus found that Zika virus RNA can be detected in both maternal and infant serum five days after delivery (Besnard et al., 2014). Even though the study size was small, Besnard and colleagues detected a significant possibility of Zika transmission after birth during breastfeeding.

Diagnosis
Diagnosis can only be confirmed by laboratory testing... Infection with Zika virus may be suspected based on symptoms and place of residence or history of travel to an area where Zika virus is known to be present. Diagnosis can only be confirmed by laboratory testing for the presence of Zika virus RNA in the blood or other body fluids, such as urine or saliva (WHO, 2016d). There are no commercially available tests for Zika, with testing currently preformed at laboratories and some regional health institutions (Staples et al., 2016). Consequently, it is important for health organizations to implement interventions such as public screening and education about preventing human-to-human transmission of Zika.

Public Health Concerns about Zika Virus

During large outbreaks in French Polynesia and Brazil in 2013 and 2015 respectively, national health authorities reported potential neurological and auto-immune complications of Zika virus disease. Recently in Brazil, local health authorities have observed an increase in GBS which coincided with Zika virus infections in the general public, and an increase in babies born with microcephaly in northeast Brazil. Substantial new research has strengthened the association between Zika infection and the occurrence of foetal malformations and neurological disorders. However, more investigation is needed to better understand the relationship. Researchers are also investigating other potential causes (Cao-Lormeau et al., 2016; WHO, 2016c).

Pregnancy, Microcephaly, and Zika Virus
Currently, no vaccine is available, although clinical trials have begun. During 2016, concern escalated in regard to pregnancy, with public health authorities in Colombia, Ecuador, El Salvador, and Jamaica all issuing an unprecedented health notices warning residents to avoid pregnancy until 2018 (Yakob & Walker, 2016). Currently, no vaccine is available, although clinical trials have begun. (WHO, 2016d).

Microcephaly is a rare condition where a baby is born with a small head, or the head stops growing after birth (WHO, 2016b). Since its discovery there, Brazil has experienced the highest rate of Zika virus disease of all countries and in addition, within a six-month period, thousands of babies with microcephaly have been born (Adibi, Marques, Cartus, & Beigi, 2016). To complicate the situation, how the Zika virus causes foetal microcephaly is unknown.

Addressing this tragic situation by understanding the means of infection is of the utmost urgency... Miscarriage of pregnancy and death of the infant in the first few days of life can result. Microcephaly may be present at birth or it may develop in the first few years of life (National Institute of Neurological Disorders and Stroke [NINDS], 2016). Often people with the disorder have an intellectual disability, poor motor function, poor speech, abnormal facial features, seizures, and are short in stature (NINDS, 2016) There is no specific treatment and in general, life expectancy for individuals with microcephaly is reduced, and the prognosis for normal brain function is poor. Addressing this tragic situation by understanding the means of infection is of the utmost urgency to inform efforts for early detection, therapeutic responses, and preparedness for epidemics (Adibi et al., 2016)

Guillain–Barré Syndrome and Zika Virus
Guillain-Barré syndrome is a rare condition in which the human immune system attacks peripheral nerves (WHO, 2016a). People of all ages can be affected, but it is more common in adults and in males. Severe cases are rare, but can result in near-total paralysis. Most people recover fully from even the most severe cases of GBS. Treatment includes supportive care and some immunological therapies (WHO, 2016a).

French Polynesia experienced the largest Zika virus outbreak ever described... coupled with an increase in GBS. French Polynesia experienced the largest Zika virus outbreak ever described between October 2013 and April 2014, coupled with an increase in GBS (WHO, 2016a). This suggested a possible association between Zika virus and Guillain-Barré syndrome (Cao-Lormeau et al., 2016).

Other arboviral diseases like chikungunya, dengue, Japanese encephalitis, and West Nile had already been reported to sometimes cause GBS; only during the outbreak in French Polynesia was this severe neurological complication first described as associated with Zika virus infection (Cao-Lormeau et al., 2016). Zika virus infection should be considered in patients with acute myelitis living in or travelling from endemic areas. Further study is needed clarify the spectrum and incidence of neurological associations (Mécharles et al., 2016).

Given the increase of congenital anomalies, GBS, and other neurological and autoimmune syndromes in areas where Zika virus is circulating, the PAHO/WHO recommends its Member States establish and maintain capacity to detect and confirm Zika virus cases; prepare healthcare facilities to respond to a possible increased demand of specialized care for neurological syndromes; and strengthen antenatal care. In addition, countries are urged to continue with efforts to reduce the presence of mosquito vectors through an effective vector control strategy and communication to the public (PAHO/WHO, 2016). As Zika virus disease spreads rapidly across the Americas, at risk countries have been advised to prepare adequate intensive care beds to manage patients with GBS. (Cao-Lormeau et al., 2016)

Public Health Strategies for Zika Virus

As previously noted, there is no specific treatment or vaccine currently available to treat Zika virus. Failure by the pharmaceutical industry to have a vaccine prepared is perhaps understandable (Mullan, 2016), but even the attempt to address the global outbreaks with vaccine development is anticipated to take several years (Yakob & Walker, 2016).

The best form of prevention is protection against mosquito bites. The best form of prevention is protection against mosquito bites. Therefore, public health authorities arestrongly urged to control mosquitos through effective vector control strategies. Mosquitoes and their breeding sites pose a significant risk factor for Zika virus infection. Prevention and control relies on reducing mosquitoes through removal and modification of breeding sites and reduction of contact between mosquitoes and people. When people in local communities understand efforts by local government to reduce the density of mosquitoes, they are more likely to offer support. Thus, it is important to help residents understand the risks at hand.

...it is important to help residents understand the risks at hand. Self-protective measures include insect repellent; wearing clothes (preferably light-coloured, long-sleeved pants and shirts, socks and shoes) that cover as much of the body as possible; installing physical barriers (e.g., window screens in buildings, closed doors and windows); and if needed, additional personal protection, such as sleeping under mosquito nets during the day. It is extremely important to empty, clean, or cover containers that can store water (e.g., buckets, drums, pots). Other mosquito breeding sites should be cleaned or removed, including flower pots, used tyres, and roof gutters. Efforts must be made to eliminate mosquito breeding sites in and around houses, such as accumulated still water soon after rains and/or water filled discarded containers and waste materials. Travelers should also take the basic precautions described above to protect themselves from mosquito bites. (WHO, 2016d)

Sexual transmission of Zika virus is possible and of increasing concern. Sexual transmission of Zika virus is possible and of increasing concern (WHO, 2016d). Sex partners of pregnant women who may live or return from areas where local transmission of Zika virus occurs should practice safer sex (e.g., wearing condoms, abstaining throughout the pregnancy). In general, people living in areas where local transmission of Zika virus occurs should practice safer sex or abstain from sexual activity. In addition, people returning from areas where local transmission of Zika virus occurs should adopt safer sexual practices or consider abstinence for at least four weeks after their return to reduce the risk of onward transmission to the new location. (WHO, 2016d)

Responses to Zika Virus for Nurses

This section will discuss responses nurses can make to manage the outbreak of Zika virus. Topics discussed will include providing direct care; rules in health policy planning and management; managing outbreaks; and the nursing contribution in research and evidence-based practice.

Providing Direct Care
In endemic/pandemic situations, community education is vital. As patient advocates, nurses have significant influence to change patients’ health behaviours. Nurses are in a position to notice early symptoms of infection and thus make an important contribution to help recognise and report outbreak situations (Gould, 2013). It is therefore nurses’ responsibility, on behalf of people in need, to help control the spread of this virus. In endemic/pandemic situations, community education is vital.

Zika virus effects are usually relatively mild and require no specific treatment. People ill from Zika exposure require plentiful rest and fluids, and treatment for pain and fever with common analgesic/antipyretic medicines. If symptoms worsen, they should seek medical care and advice (WHO, 2016d).

Strategies may involve going door to door to educate individuals and entire communities about preventing transmission and protecting themselves from the disease. To effectively support patients with potential or diagnosed Zika virus disease, nurses need to keep abreast of the latest information and guidelines. It is important that nurses also care for themselves before they care for others. Nurses must use their skills as critical thinkers and knowledge brokers who the public may trust to approach for accurate information. Strategies may involve going door to door to educate individuals and entire communities about preventing transmission and protecting themselves from the disease. Similar education opportunities for education include community and school groups. Where patients are positive with Zika virus, nurses have the capability to discuss pathways of Zika transmission and inform patients about how to protect others.

Engaging sex partners in discussions can be helpful... For women of reproductive age and their sex partners, all nurses, and especially midwives, may provide counselling and suggest delaying pregnancy, as recommended by the World Health Organisation (WHO, 2016d). Engaging sex partners in discussions can be helpful so that both persons understand the benefit of delaying pregnancy and are active and positive participants in safer sex to achieve disease prevention.

Personal repellents should contain DEET (N, N-diethyl-3-methylbenzamide), IR3535 (3-[N-acetyl-N-butyl]-aminopropionic acid ethyl ester) or icaridin (1-piperidinecarboxylic acid, 2-(2-hydroxyethyl)-1-methylpropylester) and product label instructions strictly followed (WHO, 2016d). Special attention and help should be given to those who may not be able to protect themselves adequately, such as young children, the sick, or the elderly.

Nurses must consider potential risks when caring for patients with infectious diseases. In a position statement related to risks and responsibilities for nurses while providing care, the American Nurses Association (ANA) acknowledges that some patients' health problems may "… raise questions for the nurse regarding personal risk and responsibility for patient care” (ANA, 2015, p. 2.) To resolve this, the nurse must engage in critical thinking and ethical analysis. For example, caring for a patient with an infectious disease that may place the nurse at risk of harm is a moral duty rather than a moral option if all of the following criteria are met: “The patient is at significant risk of harm, loss, or damage if the nurse does not assist; The nurse's intervention or care is directly relevant to preventing harm; The nurse's care will probably prevent harm, loss, or damage to the patient; and The benefit the patient will gain outweighs any harm the nurse might incur and does not present more than an acceptable risk to the nurse” (ANA, 2015, p. 2-3.). In sum, nurses are required and expected to be knowledgeable about protective measures, and to use these when providing care for patients.

Knowledge of the Zika virus is continually evolving... Knowledge of the Zika virus is continually evolving and it is nurses’ responsibility to keep currency with the evolving body of knowledge surrounding Zika virus infection in order to provide optimal patient care. The best ways for nurses to minimize personal risks to ensure that they will feel safe continuing to care for patients during a pandemic are to become educated about the facts and implications of the disease; to become familiar with the nursing professional code of ethics; and to become involved in planning efforts at their healthcare organizations (Gould, 2013). Table 2 provide selected resources about Zika virus that readers may find helpful in education and practice.

Table 2. Selected Information about Zika Virus for Education and Practice

Greater Roles in Health Policy Planning and Management
Nurses can significantly influence Zika health policy, planning, and management. Nurses can significantly influence Zika health policy, planning, and management. Being visible and engaged with communities, nurses are able to take a strong position to enhance surveillance of Zika virus disease and potential complications; help authorities meet commitments under international health regulations; support implementation of vector control strategies to reduce Aedes mosquito populations (e.g., providing larvicide to treat still water sites that cannot be treated by cleaning, emptying, or covering). As advocates, nurses may campaign for governments to fund mosquito net distribution, especially in rural and poor areas. Most importantly, nurses can prepare recommendations for clinical care and follow-up of people with Zika virus disease, in collaboration with experts and health agencies.

A particularly exciting and potentially impactful endeavour is seeking collaborations focusing on training the trainers and providing access to context-relevant curricula across a range of medical and non-medical skill sets (Martin, Mullan, & Horton, 2016). The hope is that this will strengthen training programmes; address deficits in human resource skills; and educate all about how to implement long-term partnerships to achieve prevention and effective treatment (Martin et al., 2016). The nurse role in these types of initiatives is potentially invaluable.

Managing Outbreaks of Zika Infection
In support of nurse clinicians, nurse educators have a responsibility to provide training about diagnosis, vector control, and clinical management, via a number of WHO Collaborating Centres. Through their work with the Health Protection Agency, Hird, Lighton, McEvoy, and Morgan (2012) created standards and an action plan to manage outbreaks of infectious diseases, with the primary objective to protect the public and prevent further spread. These guidelines provide a blueprint for best practice, but they must be adopted according to local need and are meant to be used flexibly. The guidelines suggest that once an outbreak has been recognised, investigations should begin within 24 hours with immediate risk assessment and the formal convening of an outbreak control team (Gould, 2013).

Opportunities for Nursing Research and Evidence-Based Practice
Nurses have opportunity for involvement at the forefront of Zika virus research. Considering experiences in everyday practice, nurses can define and prioritize research needs related to the Zika virus. There are opportunities for collaborative research with non-nursing experts and partners.

...rapid data sharing is critical during an unfolding health emergency. Data are the basis for public health action, and rapid data sharing is critical during an unfolding health emergency (Dye, Bartolomeos, Moorthy, & Kieny, 2016). Information disseminated through peer-reviewed journals and accompanying online data sets is vital to inform decision-makers (Dye et al., 2016). Nurses need to use evidence-based practice skills to translate current information related to Zika virus infection; assist in decisions about taking preventive actions (e.g., where and how); and evaluate needs for health promotion and education at local, regional, and global levels.

Limitations

 There is limited research and data available about... the Zika virus to date. The roles, responsibilities, and implications for nurses described in this article are not exhaustive. There is limited research and data available about the assessment, management, and potential and actual impact of the Zika virus to date. New knowledge is continually evolving. The contribution of this article is to concisely summarize and synthesize what is known and how nurses might respond. It is up to nurses and midwives to evaluate and report individual level impact to control and manage Zika virus disease.

Conclusion

The Zika outbreak has become a topic of interest to a global audience and is now considered a global health emergency by WHO (2016c). Recommendations are available but changes are frequent as new knowledge emerges. The virus is transmitted primarily by the mosquito vector, Aedes aegypti. But there is new information and serious concern about sexual transmission (Besnard et al., 2014; WHO 2016b). Although Zika virus disease symptoms have been known to be mild, there have been foetal complications, including microcephaly and intracranial calcifications associated with infection in pregnant women. Zika virus has also been associated with Guillain-Barre Syndrome (WHO, 2016a; 2016c).

The Americas, and the world, await the long-term impact of the Zika virus. The Americas, and the world, await the long-term impact of the Zika virus. Nurses will make important contributions toward effective management of prevention and treatment strategies, including supporting and implementing appropriate interventions and using their long-standing professional history of response to crises and well-established public trust to provide public health education.

Authors

Anne Wilson, PhD, MN, BN, RN, RM, FACN
Email: anne.wilson@adelaide.edu.au

Anne Wilson is a professor at the School of Medicine, Flinders University of South Australia and School of Medicine, University of Adelaide, North Terrace, Adelaide, South Australia. Dr. Wilson is an experienced public health nurse and midwife who has worked with infectious disease outbreaks in remote areas.

Thi Ngoc Minh Nguyen, RN, BN, MNSc
Email: n2minh87@gmail.com

Thi Ngoc Minh Nguyen is a nursing lecturer, at School of Nursing, Eastern International University, Binh Duong, Vietnam.