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Disease control programs are needed to identify the breeding sites of mosquitoes, which transmit malaria and other diseases, in order to target interventions and identify environmental risk factors. The increasing availability of very-high-resolution drone data provides new opportunities to find and characterize these vector breeding sites. Within this study, drone images from two malaria-endemic regions in Burkina Faso and Côte d'Ivoire were assembled and labeled using open-source tools. We developed and applied a workflow using region-of-interest-based and deep learning methods to identify land cover types associated with vector breeding sites from very-high-resolution natural color imagery. Analysis methods were assessed using cross-validation and achieved maximum Dice coefficients of 0.68 and 0.75 for vegetated and non-vegetated water bodies, respectively. This classifier consistently identified the presence of other land cover types associated with the breeding sites, obtaining Dice coefficients of 0.88 for tillage and crops, 0.87 for buildings and 0.71 for roads. This study establishes a framework for developing deep learning approaches to identify vector breeding sites and highlights the need to evaluate how results will be used by control programs.

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A new optical method for assigning glass viscosity values in the softening temperature range is presented. In this method, an irregular particle, a few millimeters in size, laying on an alumina plate, is heated up to temperature T, and then remains at this temperature. T should be within the softening temperature range of the glass. There are no external applied shear stresses, the only acting shear forces are those coming from the particle's own surface energy. At the fixed temperature T, the surface free energy of the sample decreases by viscous flow while its shape evolves from a polyhedron or irregular shape towards a spherical or rounded shape. This shape evolution is recorded using a photographic camera. From each image, the sample's roundness is determined, obtaining a characteristic time τ from the roundness against time. Simultaneously, using the available software, a value for the viscosity η was calculated, at temperature T, allowing for building sets of T, τ, η, namely three data values. Accordingly, if T, τ are considered as independent variables, a master function η = η (T, τ) can be built. Now, if we measure T, τ data on a glass of an unknown viscosity, the master function makes it possible to assign a η value. When incipient crystallization or liquid-liquid phase separations are present, effective viscosity values are obtained. This method requires a high temperature microscope, as well as tridimmensional samples with a few cubic millimeters of volume. Each isothermal τ determination can take from minutes to several hours. We tested the method with two glasses of known viscosity values: borosilicate glass (VG98) and alumimoborosilicate glass (SG7), both of which are used for radioactive waste immobilization and have assigned log(η) values between 6 and 7.3 with η in Pa s. The discrepancy between the log(η) values assigned here and those values fitted with a VFT function on the values measured for the SG7 and VG98 glasses were within ±14%.

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Resumen Introducción: La pandemia COVID-19 generó una reestructuración en la atención quirúrgica mundialmente debido a su alta transmisibilidad y la inherente limitación de los recursos humanos y materiales disponibles. Objetivo: Describir el impacto de la pandemia COVID-19 en el Equipo de Cirugía Cabeza y Cuello del Complejo Asistencial Barros Luco Trudeau (CABL) en su ejecución clínico-quirúrgica y la secuenciación organizada de las medidas sanitarias aplicadas a lo largo del tiempo durante los primeros 150 días de iniciada la pandemia en Chile. Materiales y Método: Realizamos una revisión retrospectiva de los pacientes sometidos a cirugía y/o evaluados ambulatoriamente durante el período COVID-19 comprendido entre el 3 de marzo y el 31 de julio de 2020, comparado con el mismo intervalo de tiempo de 2019. Características clínicas y medidas sanitarias empleadas durante este período fueron sintetizadas. Resultados: Detectamos un descenso del 64% en atención ambulatoria y un descenso del 58% en la carga quirúrgica, comparado con el año 2019. Durante el período COVID-19 de 2020, un total de 61 pacientes fueron sometidos a intervención quirúrgica. La principal indicación de cirugía fue cáncer en un 75,4% (46). No se reportaron pacientes contagiados por COVID-19 en los 14 días siguientes a la hospitalización. Se discuten las consideraciones perioperatorias empleadas y restricciones nacionales/institucionales sanitarias. Conclusión: La crisis sanitaria mundial secundaria al COVID-19 generó una reducción en las atenciones ambulatorias y cirugías realizadas por Equipo de Cabeza y Cuello CABL. A pesar de las restricciones sanitarias, organizamos estratificadamente la atención para preservar la resolución de casos críticos no diferibles en cabeza y cuello.

Introduction: The COVID-19 pandemic generated a restructuring of surgical care worldwide due to the disease's high transmissibility and the inherent limitation of available human and material resources. Aim: The study's aim was to describe the impact of the COVID-19 pandemic on the head and neck surgery team at Complejo Asistencial Barros Luco Trudeau (CABL) in clinical-surgical execution and organization of sanitary sequencing measures implemented over time during the first 150 days after the pandemic started in Chile. Materials and Method: We performed a retrospective review of patients undergoing surgery or outpatient evaluation during the COVID-19 period from 03-03-2020 to 07-31-2020, compared to the same time interval in 2019. Clinical characteristics and sanitary measures used during this period were synthesized. Results: We detected a 64% decrease in outpatient care and a 58% decrease in surgical load from 2019. During the COVID-19 period of 2020, a total of 61 patients underwent surgical intervention. The main indication for surgery was cancer, in 75.4% of patients (46). COVID-19 was not reported in any patients in the 14 days following hospitalization. We discussed the perioperative considerations used and the national/institutional sanitary restrictions. Conclusions: The global health crisis to COVID-19 generated a reduction in outpatient care and surgeries performed by the CABL head and neck team. Despite health restrictions, we organized care stratified to preserve critical head and neck non-deferrable cases.

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We evaluated nucleic acid amplification testing (NAAT) for Zika virus on whole-blood specimens compared with NAAT on serum and urine specimens among asymptomatic pregnant women during the 2015-2016 Puerto Rico Zika outbreak. Using NAAT, more infections were detected in serum and urine than in whole blood specimens.

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In the last decades, the development of interconnectivity, pervasive systems, citizen sensors, and Big Data technologies allowed us to gather many data from different sources worldwide. This phenomenon has raised privacy concerns around the globe, compelling states to enforce data protection laws. In parallel, privacy-enhancing techniques have emerged to meet regulation requirements allowing companies and researchers to exploit individual data in a privacy-aware way. Thus, data curators need to find the most suitable algorithms to meet a required trade-off between utility and privacy. This crucial task could take a lot of time since there is a lack of benchmarks on privacy techniques. To fill this gap, we compare classical approaches of privacy techniques like Statistical Disclosure Control and Differential Privacy techniques to more recent techniques such as Generative Adversarial Networks and Machine Learning Copies using an entire commercial database in the current effort. The obtained results allow us to show the evolution of privacy techniques and depict new uses of the privacy-aware Machine Learning techniques.

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OBJECTIVES: Using the Council of State and Territorial Epidemiologists (CSTE) classification guidelines, we characterized coronavirus disease 2019 (COVID-19)-associated confirmed and probable deaths in Puerto Rico during March-July 2020. We also estimated the total number of possible deaths due to COVID-19 in Puerto Rico during the same period. METHODS: We described data on COVID-19-associated mortality, in which the lower bound was the sum of confirmed and probable COVID-19 deaths and the upper bound was excess mortality, estimated as the difference between observed deaths and average expected deaths. We obtained data from the Puerto Rico Department of Health COVID-19 Mortality Surveillance System, the Centers for Disease Control and Prevention's National Electronic Disease Surveillance System Base System, and the National Center for Health Statistics. RESULTS: During March-July 2020, 225 COVID-19-associated deaths were identified in Puerto Rico (119 confirmed deaths and 106 probable deaths). The median age of decedents was 73 (interquartile range, 59-83); 60 (26.7%) deaths occurred in the Metropolitana region, and 140 (62.2%) deaths occurred among men. Of the 225 decedents, 180 (83.6%) had been hospitalized and 93 (41.3%) had required mechanical ventilation. Influenza and pneumonia (48.0%), sepsis (28.9%), and respiratory failure (27.1%) were the most common conditions contributing to COVID-19 deaths based on death certificates. Based on excess mortality calculations, as many as 638 COVID-19-associated deaths could have occurred during the study period, up to 413 more COVID-19-associated deaths than originally reported. CONCLUSIONS: Including probable deaths per the CSTE guidelines and monitoring all-cause excess mortality can lead to a better estimation of COVID-19-associated deaths and serve as a model to enhance mortality surveillance in other US jurisdictions.

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El Niño is an extreme weather event featuring unusual warming of surface waters in the eastern equatorial Pacific Ocean. This phenomenon is characterized by heavy rains and floods that negatively affect the economic activities of the impacted areas. Understanding how this phenomenon influences consumption behavior at different granularity levels is essential for recommending strategies to normalize the situation. With this aim, we performed a multi-scale analysis of data associated with bank transactions involving credit and debit cards. Our findings can be summarized into two main results: Coarse-grained analysis reveals the presence of the El Niño phenomenon and the recovery time in a given territory, while fine-grained analysis demonstrates a change in individuals' purchasing patterns and in merchant relevance as a consequence of the climatic event. The results also indicate that society successfully withstood the natural disaster owing to the economic structure built over time. In this study, we present a new method that may be useful for better characterizing future extreme events.

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In this work we present a new type of scaffold obtained by solid-state reaction, simultaneous sintering of a mixture of precursor oxides, carbonates, and organic substances, the latter used for pore generation. Having variable local composition, exhibits excellent overall physicochemical and bioactivity response. Open porosity is about 50%-60% and its permeability 10-11  m2 . X-ray diffraction exhibits the presence of a sodium-calcium silicate and sodium-calcium phosphate crystalline phases. Additionally, by mechanical compression tests the range of failure stress obtained for the scaffolds was 0.3-1.1 MPa. The bioactivity and dissolution rate of the scaffolds were evaluated by in vitro tests. After 1 week soaking in simulated body fluid, the formation of a continuous hydroxyapatite layer, which does not differentiate local compositions, was observed. Our results from cell culture tests clearly indicate that during hydroxyapatite layer formation, scaffolds do not liberate any cytotoxic substances. Moreover, cells seeded in the hydroxyapatite-covered scaffolds grew better than the control.

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Zika virus infection during pregnancy can cause congenital brain and eye abnormalities and is associated with neurodevelopmental abnormalities (1-3). In areas of the United States that experienced local Zika virus transmission, the prevalence of birth defects potentially related to Zika virus infection during pregnancy increased in the second half of 2016 compared with the first half (4). To update the previous report, CDC analyzed population-based surveillance data from 22 states and territories to estimate the prevalence of birth defects potentially related to Zika virus infection, regardless of laboratory evidence of or exposure to Zika virus, among pregnancies completed during January 1, 2016-June 30, 2017. Jurisdictions were categorized as those 1) with widespread local transmission of Zika virus; 2) with limited local transmission of Zika virus; and 3) without local transmission of Zika virus. Among 2,004,630 live births, 3,359 infants and fetuses with birth defects potentially related to Zika virus infection during pregnancy were identified (1.7 per 1,000 live births, 95% confidence interval [CI] = 1.6-1.7). In areas with widespread local Zika virus transmission, the prevalence of birth defects potentially related to Zika virus infection during pregnancy was significantly higher during the quarters comprising July 2016-March 2017 (July-September 2016 = 3.0; October-December 2016 = 4.0; and January-March 2017 = 5.6 per 1,000 live births) compared with the reference period (January-March 2016) (1.3 per 1,000). These findings suggest a fourfold increase (prevalence ratio [PR] = 4.1, 95% CI = 2.1-8.4) in birth defects potentially related to Zika virus in widespread local transmission areas during January-March 2017 compared with that during January-March 2016, with the highest prevalence (7.0 per 1,000 live births) in February 2017. Population-based birth defects surveillance is critical for identifying infants and fetuses with birth defects potentially related to Zika virus regardless of whether Zika virus testing was conducted, especially given the high prevalence of asymptomatic disease. These data can be used to inform follow-up care and services as well as strengthen surveillance.

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The COVID-19 crisis has produced worldwide changes from people's lifestyles to travel restrictions imposed by world's nations aiming to keep the virus out. Several countries have created digital information applications to help control and manage the COVID-19 crisis, such as the creation of contact tracing apps. The Peruvian government in collaboration with several institutions developed PerúEnTusManos, an epidemiological tracing application. The application uses georeferencing to study users' movements and creates individual mobility patterns from the Peruvian citizens as well as detects crowds. In this article, we present a process to detect possible infected individuals based on probabilities assigned to people that had contact with someone who tested positive for COVID-19, using data collected from PerúEnTusManos. The preliminary evaluation shows promising results when detecting probabilities of possible infected individuals as well as the most infected districts in Peru. The ultimate goal of the application in Peru is to provide reliable information to health authorities to make informed decisions about the assignations of the available clinical tests and the economic re-activation.

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INTRODUCTION: Zika virus infection during pregnancy causes serious birth defects and might be associated with neurodevelopmental abnormalities in children. Early identification of and intervention for neurodevelopmental problems can improve cognitive, social, and behavioral functioning. METHODS: Pregnancies with laboratory evidence of confirmed or possible Zika virus infection and infants resulting from these pregnancies are included in the U.S. Zika Pregnancy and Infant Registry (USZPIR) and followed through active surveillance methods. This report includes data on children aged ≥1 year born in U.S. territories and freely associated states. Receipt of reported follow-up care was assessed, and data were reviewed to identify Zika-associated birth defects and neurodevelopmental abnormalities possibly associated with congenital Zika virus infection. RESULTS: Among 1,450 children of mothers with laboratory evidence of confirmed or possible Zika virus infection during pregnancy and with reported follow-up care, 76% had developmental screening or evaluation, 60% had postnatal neuroimaging, 48% had automated auditory brainstem response-based hearing screen or evaluation, and 36% had an ophthalmologic evaluation. Among evaluated children, 6% had at least one Zika-associated birth defect identified, 9% had at least one neurodevelopmental abnormality possibly associated with congenital Zika virus infection identified, and 1% had both. CONCLUSION: One in seven evaluated children had a Zika-associated birth defect, a neurodevelopmental abnormality possibly associated with congenital Zika virus infection, or both reported to the USZPIR. Given that most children did not have evidence of all recommended evaluations, additional anomalies might not have been identified. Careful monitoring and evaluation of children born to mothers with evidence of Zika virus infection during pregnancy is essential for ensuring early detection of possible disabilities and early referral to intervention services.

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Zika virus infection during pregnancy can cause serious birth defects, including microcephaly and brain abnormalities (1). Population-based birth defects surveillance systems are critical to monitor all infants and fetuses with birth defects potentially related to Zika virus infection, regardless of known exposure or laboratory evidence of Zika virus infection during pregnancy. CDC analyzed data from 15 U.S. jurisdictions conducting population-based surveillance for birth defects potentially related to Zika virus infection.* Jurisdictions were stratified into the following three groups: those with 1) documented local transmission of Zika virus during 2016; 2) one or more cases of confirmed, symptomatic, travel-associated Zika virus disease reported to CDC per 100,000 residents; and 3) less than one case of confirmed, symptomatic, travel-associated Zika virus disease reported to CDC per 100,000 residents. A total of 2,962 infants and fetuses (3.0 per 1,000 live births; 95% confidence interval [CI] = 2.9-3.2) (2) met the case definition.† In areas with local transmission there was a non-statistically significant increase in total birth defects potentially related to Zika virus infection from 2.8 cases per 1,000 live births in the first half of 2016 to 3.0 cases in the second half (p = 0.10). However, when neural tube defects and other early brain malformations (NTDs)§ were excluded, the prevalence of birth defects strongly linked to congenital Zika virus infection increased significantly, from 2.0 cases per 1,000 live births in the first half of 2016 to 2.4 cases in the second half, an increase of 29 more cases than expected (p = 0.009). These findings underscore the importance of surveillance for birth defects potentially related to Zika virus infection and the need for continued monitoring in areas at risk for Zika.

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A composite is a material made of more than one component, and the bond between the components is on a scale larger than the atomic scale. The objective of the present study was to synthesize and perform the structural characterization and biological evaluation of a new biocomposite (BCO) based on a novel combination of an organic and an inorganic phase, for bone tissue engineering applications. The organic phase consisted of Wharton's jelly (WJ), which was obtained from embryonic tissue following a protocol developed by our laboratory. The inorganic phase consisted of bioceramic particles (BC), produced by sintering hydroxyapatite (HA) with ß- tricalcium phosphate (ß-TCP), and bioactive glass particles (BG). Each phase of the BCO was fully characterized by SEM, EDS, XRD, and FTIR. Biocompatibility was evaluated in vivo in the tibiae of Wistar rats (n = 40). Histological evaluation was performed at 0, 1, 7, 14, 30, and 60 days. XRD showed the phases corresponding to HA and ß-TCP, whereas diffractogram of BG showed it to have an amorphous structure. EDS showed mainly Si and Na, Ca, P in BG, and Ca and P in HA and ß-TCP. FTIR identified bonds between the organic and inorganic phases. From a mechanical viewpoint, the composite showed high flexural strength of 40.3 ± 0.8 MPa. The synthesized BCO exhibited adequate biocompatibility as shown by formation of lamellar type bone linked by BG and BC particles. The biomaterial presented here showed excellent mechanical and biocompatibility properties for its potential clinical use. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 1034-1045, 2017.

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We modeled the potential cost-effectiveness of increasing access to contraception in Puerto Rico during a Zika virus outbreak. The intervention is projected to cost an additional $33.5 million in family planning services and is likely to be cost-saving for the healthcare system overall. It could reduce Zika virus-related costs by $65.2 million ($2.8 million from less Zika virus testing and monitoring and $62.3 million from avoided costs of Zika virus-associated microcephaly [ZAM]). The estimates are influenced by the contraception methods used, the frequency of ZAM, and the lifetime incremental cost of ZAM. Accounting for unwanted pregnancies that are prevented, irrespective of Zika virus infection, an additional $40.4 million in medical costs would be avoided through the intervention. Increasing contraceptive access for women who want to delay or avoid pregnancy in Puerto Rico during a Zika virus outbreak can substantially reduce the number of cases of ZAM and healthcare costs.

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Zika virus is a flavivirus transmitted primarily by Aedes aegypti and Aedes albopictus mosquitoes, and infection can be asymptomatic or result in an acute febrile illness with rash (1). Zika virus infection during pregnancy is a cause of microcephaly and other severe birth defects (2). Infection has also been associated with Guillain-Barré syndrome (GBS) (3) and severe thrombocytopenia (4,5). In December 2015, the Puerto Rico Department of Health (PRDH) reported the first locally acquired case of Zika virus infection. This report provides an update to the epidemiology of and public health response to ongoing Zika virus transmission in Puerto Rico (6,7). A confirmed case of Zika virus infection is defined as a positive result for Zika virus testing by reverse transcription-polymerase chain reaction (RT-PCR) for Zika virus in a blood or urine specimen. A presumptive case is defined as a positive result by Zika virus immunoglobulin M (IgM) enzyme-linked immunosorbent assay (MAC-ELISA)* and a negative result by dengue virus IgM ELISA, or a positive test result by Zika IgM MAC-ELISA in a pregnant woman. An unspecified flavivirus case is defined as positive or equivocal results for both Zika and dengue virus by IgM ELISA. During November 1, 2015-July 7, 2016, a total of 23,487 persons were evaluated by PRDH and CDC Dengue Branch for Zika virus infection, including asymptomatic pregnant women and persons with signs or symptoms consistent with Zika virus disease or suspected GBS; 5,582 (24%) confirmed and presumptive Zika virus cases were identified. Persons with Zika virus infection were residents of 77 (99%) of Puerto Rico's 78 municipalities. During 2016, the percentage of positive Zika virus infection cases among symptomatic males and nonpregnant females who were tested increased from 14% in February to 64% in June. Among 9,343 pregnant women tested, 672 had confirmed or presumptive Zika virus infection, including 441 (66%) symptomatic women and 231 (34%) asymptomatic women. One patient died after developing severe thrombocytopenia (4). Evidence of Zika virus infection or recent unspecified flavivirus infection was detected in 21 patients with confirmed GBS. The widespread outbreak and accelerating increase in the number of cases in Puerto Rico warrants intensified vector control and personal protective behaviors to prevent new infections, particularly among pregnant women.

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IMPORTANCE: Zika virus (ZIKV) infection during pregnancy is a cause of congenital microcephaly and severe fetal brain defects, and it has been associated with other adverse pregnancy and birth outcomes. OBJECTIVE: To estimate the number of pregnant women infected with ZIKV in Puerto Rico and the number of associated congenital microcephaly cases. DESIGN, SETTING, AND PARTICIPANTS: We conducted a modeling study from April to July 2016. Using parameters derived from published reports, outcomes were modeled probabilistically using Monte Carlo simulation. We used uncertainty distributions to reflect the limited information available for parameter values. Given the high level of uncertainty in model parameters, interquartile ranges (IQRs) are presented as primary results. Outcomes were modeled for pregnant women in Puerto Rico, which currently has more confirmed ZIKV cases than any other US location. EXPOSURE: Zika virus infection in pregnant women. MAIN OUTCOMES AND MEASURES: Number of pregnant women infected with ZIKV and number of congenital microcephaly cases. RESULTS: We estimated an IQR of 5900 to 10 300 pregnant women (median, 7800) might be infected during the initial ZIKV outbreak in Puerto Rico. Of these, an IQR of 100 to 270 infants (median, 180) may be born with microcephaly due to congenital ZIKV infection from mid-2016 to mid-2017. In the absence of a ZIKV outbreak, an IQR of 9 to 16 cases (median, 12) of congenital microcephaly are expected in Puerto Rico per year. CONCLUSIONS AND RELEVANCE: The estimate of 5900 to 10 300 pregnant women that might be infected with ZIKV provides an estimate for the number of infants that could potentially have ZIKV-associated adverse outcomes. Including baseline cases of microcephaly, we estimated that an IQR of 110 to 290 total cases of congenital microcephaly, mostly attributable to ZIKV infection, could occur from mid-2016 to mid-2017 in the absence of effective interventions. The primary limitation in this analysis is uncertainty in model parameters. Multivariate sensitivity analyses indicated that the cumulative incidence of ZIKV infection and risk of microcephaly given maternal infection in the first trimester were the primary drivers of both magnitude and uncertainty in the estimated number of microcephaly cases. Increased information on these parameters would lead to more precise estimates. Nonetheless, the results underscore the need for urgent actions being undertaken in Puerto Rico to prevent congenital ZIKV infection and prepare for affected infants.

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Zika virus is a cause of microcephaly and brain abnormalities (1), and it is the first known mosquito-borne infection to cause congenital anomalies in humans. The establishment of a comprehensive surveillance system to monitor pregnant women with Zika virus infection will provide data to further elucidate the full range of potential outcomes for fetuses and infants of mothers with asymptomatic and symptomatic Zika virus infection during pregnancy. In February 2016, Zika virus disease and congenital Zika virus infections became nationally notifiable conditions in the United States (2). Cases in pregnant women with laboratory evidence of Zika virus infection who have either 1) symptomatic infection or 2) asymptomatic infection with diagnosed complications of pregnancy can be reported as cases of Zika virus disease to ArboNET* (2), CDC's national arboviral diseases surveillance system. Under existing interim guidelines from the Council for State and Territorial Epidemiologists (CSTE), asymptomatic Zika virus infections in pregnant women who do not have known pregnancy complications are not reportable. ArboNET does not currently include pregnancy surveillance information (e.g., gestational age or pregnancy exposures) or pregnancy outcomes. To understand the full impact of infection on the fetus and neonate, other systems are needed for reporting and active monitoring of pregnant women with laboratory evidence of possible Zika virus infection during pregnancy. Thus, in collaboration with state, local, tribal, and territorial health departments, CDC established two surveillance systems to monitor pregnancies and congenital outcomes among women with laboratory evidence of Zika virus infection(†) in the United States and territories: 1) the U.S. Zika Pregnancy Registry (USZPR),(§) which monitors pregnant women residing in U.S. states and all U.S. territories except Puerto Rico, and 2) the Zika Active Pregnancy Surveillance System (ZAPSS), which monitors pregnant women residing in Puerto Rico. As of May 12, 2016, the surveillance systems were monitoring 157 and 122 pregnant women with laboratory evidence of possible Zika virus infection from participating U.S. states and territories, respectively. Tracking and monitoring clinical presentation of Zika virus infection, all prenatal testing, and adverse consequences of Zika virus infection during pregnancy are critical to better characterize the risk for congenital infection, the performance of prenatal diagnostic testing, and the spectrum of adverse congenital outcomes. These data will improve clinical guidance, inform counseling messages for pregnant women, and facilitate planning for clinical and public health services for affected families.

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Zika virus is a flavivirus transmitted primarily by Aedes species mosquitoes, and symptoms of infection can include rash, fever, arthralgia, and conjunctivitis (1).* Zika virus infection during pregnancy is a cause of microcephaly and other severe brain defects (2). Infection has also been associated with Guillain-Barré syndrome (3). In December 2015, Puerto Rico became the first U.S. jurisdiction to report local transmission of Zika virus, with the index patient reporting symptom onset on November 23, 2015 (4). This report provides an update to the epidemiology of and public health response to ongoing Zika virus transmission in Puerto Rico. During November 1, 2015-April 14, 2016, a total of 6,157 specimens from suspected Zika virus-infected patients were evaluated by the Puerto Rico Department of Health (PRDH) and CDC Dengue Branch (which is located in San Juan, Puerto Rico), and 683 (11%) had laboratory evidence of current or recent Zika virus infection by one or more tests: reverse transcription-polymerase chain reaction (RT-PCR) or immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA). Zika virus-infected patients resided in 50 (64%) of 78 municipalities in Puerto Rico. Median age was 34 years (range = 35 days-89 years). The most frequently reported signs and symptoms were rash (74%), myalgia (68%), headache (63%), fever (63%), and arthralgia (63%). There were 65 (10%) symptomatic pregnant women who tested positive by RT-PCR or IgM ELISA. A total of 17 (2%) patients required hospitalization, including 5 (1%) patients with suspected Guillain-Barré syndrome. One (<1%) patient died after developing severe thrombocytopenia. The public health response to the outbreak has included increased laboratory capacity to test for Zika virus infection (including blood donor screening), implementation of enhanced surveillance systems, and prevention activities focused on pregnant women. Vector control activities include indoor and outdoor residual spraying and reduction of mosquito breeding environments focused around pregnant women's homes. Residents of and travelers to Puerto Rico should continue to employ mosquito bite avoidance behaviors, take precautions to reduce the risk for sexual transmission (5), and seek medical care for any acute illness with rash or fever.

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Zika virus, a mosquito-borne flavivirus, spread to the Region of the Americas (Americas) in mid-2015, and appears to be related to congenital microcephaly and Guillain-Barré syndrome (1,2). On February 1, 2016, the World Health Organization (WHO) declared the occurrence of microcephaly cases in association with Zika virus infection to be a Public Health Emergency of International Concern.* On December 31, 2015, Puerto Rico Department of Health (PRDH) reported the first locally acquired (index) case of Zika virus disease in a jurisdiction of the United States in a patient from southeastern Puerto Rico. During November 23, 2015-January 28, 2016, passive and enhanced surveillance for Zika virus disease identified 30 laboratory-confirmed cases. Most (93%) patients resided in eastern Puerto Rico or the San Juan metropolitan area. The most frequently reported signs and symptoms were rash (77%), myalgia (77%), arthralgia (73%), and fever (73%). Three (10%) patients were hospitalized. One case occurred in a patient hospitalized for Guillain-Barré syndrome, and one occurred in a pregnant woman. Because the most common mosquito vector of Zika virus, Aedes aegypti, is present throughout Puerto Rico, Zika virus is expected to continue to spread across the island. The public health response in Puerto Rico is being coordinated by PRDH with assistance from CDC. Clinicians in Puerto Rico should report all cases of microcephaly, Guillain-Barré syndrome, and suspected Zika virus disease to PRDH. Other adverse reproductive outcomes, including fetal demise associated with Zika virus infection, should be reported to PRDH. To avoid infection with Zika virus, residents of and visitors to Puerto Rico, particularly pregnant women, should strictly follow steps to avoid mosquito bites, including wearing pants and long-sleeved shirts, using permethrin-treated clothing and gear, using an Environmental Protection Agency (EPA)-registered insect repellent, and ensuring that windows and doors have intact screens.

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