July 6, 2016

Dear Colleague:

Now that the weather is warmer, Virginians are spending more time outdoors, increasing their exposure to mosquitoes and mosquito-related diseases, as well as ticks and tickborne diseases, including Lyme disease. This letter is provided as an update on Zika in Virginia and also includes important reminders about tickborne illness in Virginia.

This correspondence includes:

Zika Updates
Information about Zika virus disease continues to evolve as we learn more about the condition. Please check the VDH Zika Website regularly for the most up to date information.

  • Zika virus testing in infants: recommendations for testing within two days of birth
  • Maternal Health – Pediatric Provider Communications
    • For providers caring for Zika Pregnancy Registry-eligible women, please ensure that appropriate clinical records are passed on to other relevant maternity and pediatric providers in a timely way, ideally immediately before or upon birth of the infant in order to ensure appropriate clinical evaluation of the infant at birth. 
  • Symptomatic person with a negative rRT-PCR test: recommendations for additional serology testing 
    • The CDC recommends that for symptomatic patients, all specimens negative for Zika RNA via rRT-PCR be submitted for serology testing. Providers who request molecular testing for Zika virus infection from a commercial testing laboratory are advised to retain and store a serum sample for subsequent Zika IgM ELISA testing if the rRT-PCR is negative. Serology testing for Zika virus is currently only available through public health, and approval of testing is required. Providers can contact their local health department to request public health testing at DCLS.

Background Information on Tickborne Illnesses
Lyme disease activity continues to expand its geographic range in Virginia. In 2015, public health reported 1,539 confirmed and probable cases of Lyme disease in Virginia residents, more than in any previous year. Although Lyme disease is the most commonly reported tickborne illness in Virginia, other tickborne illnesses also warrant attention. Ehrlichiosis is the second most confirmed tickborne disease in Virginia. Ehrlichiosis is carried by the lone star tick, which is the most common cause of tick bites in Virginia; surveys show that ehrlichiosis agents are relatively common in these ticks. Illnesses due to the spotted fever group (SFG) rickettsia, such as Rocky Mountain spotted fever (RMSF) and Tidewater spotted fever caused by Rickettsia parkeri, are uncommon but do remain a concern. For more information, please visit the VDH Tickborne Disease Prevention and Control web page.

Updated CDC MMWR on Tickborne Rickettsial Diseases
I’d like to highlight a May 2016 CDC MMWR Report entitled: “Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis – US.” This document updates the CDC’s 2006 recommendations and can assist providers with the following:

  • Recognizing key epidemiologic features and clinical manifestations of tickborne rickettsial diseases;
  • Recognizing appropriate treatment, including that doxycycline is the treatment of choice for suspected tickborne rickettsial diseases in adults and children;
  • Understanding that early empiric therapy can prevent severe disease and death;
  • Understanding appropriate laboratory diagnostic tests, including their uses and limitations.

Actions for Healthcare Providers
Given the impact of tickborne illnesses in Virginia, please consider the following actions this tick season:

  • Report cases of the following tickborne illnesses to your local health department promptly: Ehrlichiosis/Anaplasmosis, Lyme disease, and Spotted Fever Rickettsiosis. 
  • Remind patients to take preventive steps, including recognizing and avoiding tick habitats, using insect repellent in likely tick habitats, removing attached ticks promptly, and creating tick-safe zones in the yard. 
  • Ask about tick exposure when evaluating patients with febrile illness with or without a rash.
  • Familiarize yourself with the laboratory assays available to diagnose tickborne illness. To learn more, please review the following document/link entitled, “Recommended Laboratory Assays for Select Tickborne Diseases.” Specific information on Lyme disease lab testing is available on the CDC web page.

Should you have any questions about Zika virus disease or tickborne illnesses in Virginia you may contact your local health department. Questions may also be directed to David Gaines, PhD, State Public Health Entomologist, in the VDH Office of Epidemiology. He can be reached by telephone at (804) 864-8192 or by email at david.gaines@vdh.virginia.gov. View VDH’s animated videos on tick bite prevention at http://www.tickfreesummer.com and share them widely.

Working together we can make it more likely that people in Virginia will have a safe, “Zika-free” and “tick-free” summer. Thank you for all you do.


Marissa J. Levine, MD, MPH, FAAFP

State Health Commissioner