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Zika virus infection: Latest recommendations for providers caring for reproductive-aged women

The Zika virus, a mosquito-borne flavivirus,is becoming a growing concern for U.S. women in their childbearing years. The dramatic increase in the number of cases of Zika virus infection (ZVI), as well as its correlation with neurologic deficits (e.g., microcephaly in newborns), has made it crucial for healthcare providers (HCPs) to know as much as possible about identifying, treating, and preventing ZVI. This article offers up-to-date information for HCPs caring for reproductive- aged women—particularly those who are considering pregnancy or who are already pregnant— about when to test for ZVI, whom to test, and how to best inform patients about ZVI transmission and prevention.

CDC guidance for caring for pregnant women2

All pregnant women in the U.S. and U.S. territories should be assessed for possible Zika virus exposure at each prenatal care visit. Pregnant women should not travel to an area with active Zika virus transmission. Pregnant women who must travel to one of these areas should strictly follow steps to prevent mosquito bites during the trip. In addition, to avoid contracting ZVI, pregnant women whose sex partner has traveled to or resides in an area with active Zika virus transmission should use condoms or other barrier methods or abstain from sex for the duration of the pregnancy.

Part of the concern about ZVI is the lack of signs and symptoms (S/S) in up to 80% of persons infected and the vague, mild, flulike symptoms in the remaining portion, which makes identifying the disease so difficult. When S/S of ZVI do occur, they typically include rash, low-grade fever, arthralgia, fatigue, headache, and conjunctivitis.The rash, which tends to be the most prominent sign, is usually pruritic and maculopapular. It begins proximally and spreads to the extremities, with spontaneous resolution in 1-4 days.1

Symptomatic pregnant women

Pregnant women who report S/S of ZVI should be tested for it (Figure). Testing recommendations are the same regardless of the circumstances of possible exposure; however, the type of testing recommended depends on the time of evaluation relative to symptom onset. Testing of serum and urine by real-time reverse transcriptase polymerase chain reaction (rRT-PCR) is advised for pregnant women who seek care less than 2 weeks after symptom onset. This recommendation extends the previous recommendation for testing of serum from less than 1 week after symptom onset to less than 2 weeks. A positive rRT-PCR result confirms the diagnosis of recent maternal ZVI. Women with a negative rRT-PCR result should undergo both Zika virus IgM and dengue virus IgM antibody testing. If either antibody test yields positive or equivocal results, a plaque reduction neutralization test (PRNT) should be performed on the same IgM-tested sample or a subsequently collected sample to rule out false-positive results.

Pregnant women who seek care 2-12 weeks after symptom onset should first undergo Zika virus and dengue virus IgM antibody testing (see the Figure). If the Zika virus IgM antibody testing yields positive or equivocal results, reflex rRT-PCR testing should be automatically performed on the same serum sample to determine whether Zika virus RNA is present. A positive rRT-PCR result confirms the diagnosis of recent maternal ZVI. If the rRT-PCR result is negative, a positive or equivocal Zika virus IgM antibody test result should be followed by PRNT. Positive or equivocal dengue IgM antibody test results with a negative Zika virus IgM antibody test result should also be confirmed by PRNT.

Asymptomatic pregnant women

Testing recommendations for asymptomatic pregnant women with possible Zika virus exposure differ based on the circumstances of possible exposure (i.e., ongoing vs. limited exposure) and the elapsed interval since the last possible Zika virus exposure (see the Figure). Asymptomatic pregnant women living in areas without active Zika virus transmission who are evaluated less than 2 weeks after possible Zika virus exposure should be offered serum and urine rRT-PCR testing (see the Figure). A positive rRT-PCR result confirms the diagnosis of recent maternal ZVI. However, because viral RNA in serum and urine declines over time and depends on multiple factors, asymptomatic pregnant women with a negative rRT-PCR result require additional testing to exclude infection. These women should return 2-12 weeks after possible Zika virus exposure for Zika virus IgM antibody testing. A positive or equivocal IgM antibody test result should be confirmed by PRNT.

Asymptomatic pregnant women living in an area without active Zika virus transmission, and who seek care 2-12 weeks after possible Zika virus exposure, should be offered Zika virus IgM antibody testing (see the Figure). If the Zika virus IgM antibody test yields  positive or equivocal results, reflex rRT-PCR testing should be performed on the same sample. If the rRTPCR result is negative, PRNT should be performed.

As recommended in previous guidance, IgM antibody testing is recommended as part of routine obstetric care during the first and second trimesters for asymptomatic pregnant women who have an ongoing risk for Zika virus exposure (i.e., residence in or frequent travel to an area with active Zika virus transmission) (see the Figure). Reflex rRT-PCR testing is recommended for women who have a positive or equivocal Zika virus IgM antibody test result because rRT-PCR testing provides the potential for a definitive diagnosis of ZVI. Negative rRT-PCR results after a positive or equivocal Zika virus IgM antibody test result should be followed by PRNT. The decision to implement testing of asymptomatic pregnant women with ongoing risk for Zika virus exposure should be made by local health officials based on information about levels of Zika virus transmission and laboratory capacity.

Symptomatic and asymptomatic pregnant women who seek care more than 12 weeks after symptom onset or possible Zika virus exposure

For these women, IgM antibody testing might be considered. If fetal abnormalities are present, rRT-PCR testing should also be performed on maternal serum and urine. However, a negative IgM antibody test or rRT PCR result more than 12 weeks after symptom onset or possible exposure does not rule out recent ZVI because IgM antibody and viral RNA levels decline over time. Given the limitations of testing beyond 12 weeks after symptom onset or possible exposure, serial fetal ultrasonography should be considered.

Management

Management of confirmed ZVI is supportive, and includes rest, fluids, fever control, and analgesics.1 The Table provides recommendations for prenatal and postnatal management of pregnant women with laboratory evidence of confirmed or possible ZVI.

CDC guidance for HCPs caring for women of reproductive age3

Reproductive-aged women and their partners need counseling and education in accordance with their pregnancy intentions.

For couples who are not pregnant and are not planning to become pregnant in the near future

Healthcare providers should discuss strategies to prevent unintended pregnancy with these couples. When helping women choose a contraceptive method, its safety, effectiveness, availability, and acceptability should be considered. Women should be counseled to select the most effective method that they can use correctly and consistently. Long-acting reversible contraceptives, including subdermal implants and intrauterine devices, provide highly effective reversible birth control.

Couples in whom one partner has had possible Zika virus exposure will want to maximally reduce their risk for sexually transmitting Zika virus to the uninfected partner. They should use condoms consistently and correctly or abstain from sex for at least 6 months for men or 8 weeks for women after symptom onset (if symptomatic) or after the last possible Zika virus exposure (if asymptomatic). Some couples may choose to use condoms or abstain from sex for a shorter or longer period than recommended depending on their individual circumstances and risk tolerance.

For couples planning to conceive who do not live in areas with active Zika virus transmission

These couples should consider avoiding nonessential travel to areas with active Zika virus transmission. Women who have had possible Zika virus exposure through travel or sexual contact and do not have ongoing risks for exposure should wait at least 8 weeks from symptom onset (if symptomatic) or their last possible exposure (if asymptomatic) to attempt conception. Women who wait at least 8 weeks to conceive may have an increased likelihood that Zika virus no longer presents a risk for maternal–fetal transmission.

The CDC recommends that men with possible Zika virus exposure, regardless of symptom status, wait at least 6 months from symptom onset (if symptomatic) or their last possible exposure (if asymptomatic) before attempting conception with their partner. The recommendation to wait at least 6 months for asymptomatic men, as opposed to the previous recommendation to wait at least 8 weeks, is based on the range of time after symptom onset that Zika virus RNA has been detected in semen of symptomatic men and the absence of definitive data that the risk for sexual transmission differs between symptomatic and asymptomatic men. Zika virus has not been definitively cultured from semen more than 3 months after symptom onset. It is unknown whether detection of Zika virus RNA in semen indicates presence of infectious virus and the potential for transmission.

For couples who want to conceive, in which one or both partners live in areas with active Zika virus transmission

For these couples, any partner who experiences symptoms of ZVI should be tested for it. Men with results that indicate recent ZVI or unspecified flavivirus infection should wait at least 6 months from symptom onset to attempt conception with their partner; women with results that indicate recent ZVI or unspecified flavivirus infection should wait at least 8 weeks from symptom onset to attempt conception. Partners who have had symptoms of ZVI with negative Zika virus test results should talk with their HCP about timing of conception in the setting of ongoing risk for possible exposure.

Couples living in an area with active Zika virus transmission should be counseled on the possible risk for ZVI during the periconception period. The CDC has developed tools to assist HCPs with preconception counseling. HCPs should provide counseling about the potential consequences to the fetus associated with ZVI during pregnancy, such as microcephaly and other serious brain abnormalities. Women should discuss their reproductive life plans with their HCP, in the context of potential and ongoing Zika virus exposure. HCPs should review factors that might influence pregnancy timing (e.g., unknown duration of Zika virus outbreak, fertility, age, reproductive history, health history, personal values and preferences). For couples who choose to conceive, HCPs should emphasize the use of mosquito bite prevention strategies while attempting pregnancy and during pregnancy.

Conclusion

The Zika virus has been declared a public health emergency because of the ease of transmission, the relatively benign and asymptomatic viral infection it causes, and its correlation with major neurologic complications in newborns whose mothers contracted ZVI during pregnancy. A continued response from government agencies, local health officials, HCPs, and researchers remains underway to shed new light onto this growing concern. As this epidemic continues to unfold, it remains crucial to educate women of childbearing age and their partners about the inherent risks of the Zika virus and avoidance of infection.

Jessica L. Isnetto is a faculty member at Kaplan University in Orlando, Florida. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Ploudre AR, Bloch EM. A literature review of Zika virus. Emerg Infect Dis. 2016;22(7):1185-1192.

2. CDC. Update: Interim Guidance for Health Care Providers Caring for Pregnant Women with Possible Zika Virus Exposure — United States, July 2016.

3. CDC. 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.

Doctoral degrees: Looking at the options

Nurse practitioners (NPs) may choose to return to graduate school for a variety of reasons. This choice may be fueled by a desire to teach, conduct research, improve the quality of healthcare and/or healthcare systems, or expand one’s knowledge base. In recent years, anticipation that, at some point in the future, a doctorate of nursing practice (DNP) would be the required degree for entry into advanced practice nursing has spurred many master’sprepared NPs to consider a doctoral degree. The decision to pursue any doctoral degree should be a thoughtful one based on specific career goals, knowledge about available options, and ability to commit the time, energy, and financial resources required.

A doctorate in nursing or education is a terminal degree, representing the highest level of formal education. Nurses with doctoral degrees are vital to the advancement of nursing science, nursing education, and patient and population health. In addition, doctorally prepared nurses are needed to meet future demands in education, policy development, and interdisciplinary collaboration with others in the healthcare community.1 In its 2011 landmark publication The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine recommended that efforts be made to double the number of nurses with doctorates by 2020 to meet these demands.2 Doctoral options for NPs include a doctorate of philosophy (PhD) in nursing, the aforementioned DNP, and the doctorate of education (EdD). Each option has a different type of educational and outcomes focus.

PhD

The curriculum for the PhD in nursing focuses primarily on nursing theory, research, and the development of nursing knowledge and nursing science. An informal online review of PhD programs in each region of the United States revealed 36-47 as the typical range of credit hours needed to complete doctoral coursework. A dissertation is completed after doctoral coursework, with an additional 12-20 credits awarded for conducting and documenting a research study.

Most academic institutions offer part- and full-time study options. A PhD program takes 3-6 years to finish, with 7 years usually being the maximum time allowed for completion. Clinical hours are not a component of a PhD curriculum, but some mentored teaching experience may be included. The PhD curriculum typically includes courses focused on advanced qualitative and quantitative research methods, theory and knowledge development, and advanced healthcare statistics. Some PhD programs may require students to submit a scholarly portfolio that includes a résumé or curriculum vitae, accomplishments such as published works, continuing education hours earned, professional goals, and evaluation of those goals.

Many individuals with a PhD in nursing choose to teach in undergraduate- and/or graduate-level nursing programs. According to the American Association of Colleges of Nursing (AACN), a PhD program should instillteaching, leadership, and mentorship skills, as well as interdisciplinary communication skills.3 One benefit of having a PhD in nursing is the opportunity to develop and participate in research specifically pertinent to nursing science. Although having a PhD degree is not essential in terms of obtaining funding for research from various sources or partnering with expert peers on scientific projects, it is certainly helpful.4 This research can directly affect nursing practice, health policy, and the formation of subsequent evidence-based theories.5 Nurses with PhD degrees who are employed in academic settings can enjoy professional growth, satisfaction, increased independence, and co-worker support.6, 7

Academic salaries for nurses with PhD degrees may not be competitive with those of faculty in other professionsor with those of nurses in clinical and administrative roles.7 This deficit may be somewhat balanced by an academic calendar and work schedule that allow time for thoughtful development and design of scholarly works. In addition, because of increased demand, PhD-prepared nurses may be able to negotiate their contract conditions and salaries upon hire. A global nursing faculty shortage exists because of an aging faculty, a reduced hiring pool of younger faculty, and increased dependence on adjunct faculty.NPs who choose to advance their education with a PhD will likely have a wide selection of positions to choose from and/or migrate to in the future. Some NPs with a PhD degree may find roles pertaining to a research specialty and becoming a nurse scientist appealing, whereas others may choose to remain in the academic setting. The ultimate goal of earning a PhD in nursing is to conduct research leading to the development or testing of theoretical frameworks and to contribute to nursing knowledge in areas such as health promotion, disease prevention, end-of-life care, and symptom and pain management in both acute and chronic illnesses.7

DNP

The DNP is the nursing doctorate degree that has gained a great deal of attention in recent years. The DNP curriculum prepares graduates to be clinical scholars and leaders in healthcare system change.5,9 Courses found in a typical DNP curriculum focus on epidemiology, health policy, evidence-based practice, societal health trends, quality improvement (QI), and patient safety. DNP program requirements include 1,000 post-baccalaureate clinical hours. Clinical hours completed in a master’s-degree program count toward this total. Students typically complete a comprehensive clinical- or community-based project. DNP programs can be completed on a part- or full-time basis depending on the options offered by each institution and individual student needs. Based on an unofficial online survey of DNP programs in each region of the U.S., the number of post-MSN credit hours ranges from 35 to 45 to obtain a DNP degree.

DNP graduates are prepared to provide the leadership to integrate evidence-based practice in providing care for patients, families, and populations for improved health outcomes.9  This degree prepares advanced practice nurses to continue working with patients in the clinical or community setting at the highest level of nursing practice. NPs with a DNP degree may be actively involved in strengthening healthcare through quality initiatives—that is, specific areas in which better nursing practice can make a difference in improving care. For example, quality initiatives in women’s health may involve maternal mortality, infant mortality, or preterm births. Quality initiatives encourage nurse leaders to get involved, partner with other disciplines, and further their understanding of the  healthcare system.10 DNP degrees may help facilitate parity of NPs with other healthcare professionals who need to earn doctoral degrees, improve the image of nursing, and attract more individuals to nursing, as well as increase the supply of faculty for clinical instruction in selected academic environments.10

Major concerns still need to be addressed regarding DNP education. DNP programs lack consistency with regard to what constitutes clinical hours to meet the 1,000- hour clinical requirement. The same concern exists for the scholarly projects required in most DNP programs.11 Project criteria vary widely, with some resembling research similar to a dissertation, others focusing on evidence-based QI endeavors, and still others consisting of an extensive literature review of a healthcare topic.

To address these concerns, AACN’s board created a task force in early 2014 to develop a white paper. In August 2015, AACN published The Doctor of Nursing Practice: Current Issues and Clarifying Recommendations: Report from the Task Force on the Implementation of the DNP.12 The white paper describes characteristics of the DNP project, practice experiences, and practice hours. It is anticipated that DNP programs will incorporate the task force’s recommendations into their curricula.

DNP-prepared NPs can prosper in primary care settings because of their patient-centered focus, and they can help alleviate the nursing faculty shortage, especially in the role of clinical instructor. DNP graduates can contribute to the academic setting, although some research-intensive institutions do not allow faculty with DNPs to enter tenure-track positions. A challenge for DNP-prepared NPs working in the healthcare setting may be the lack of knowledge that many current or potential employers have about the benefits that these providers can bring to the organization.13, 14 DNP educators and graduates need to educate healthcare organization employers in this regard. Studies that demonstrate improved healthcare and healthcare outcomes are important.

EdD

Nurse practitioners who want to develop skills in teaching, curriculum design, and evaluation might choose to obtain the EdD. This doctoral degree focuses on preparing graduates as education researchers and scholars to add to the body of knowledge and improve educational practices and outcomes. Some EdD programs have a nursing focus, but many of them are more generalized to include individuals from a variety of professions. A typical EdD curriculum ranges from 50 to 60 credit hours and includes courses addressing teaching and learning theories, educational trends, leadership, and research with a dissertation component. NPs who wish to work with students and influence the future of the nursing profession may choose this degree.14 The EdD degree can be completed in 3-4 years, but part- and full-time status requirements vary by school. NPs with an EdD degree can thrive in the academic setting because of their background in educational theory and applied teaching methods. EdD-prepared NPs may also hold educational leadership positions in healthcare systems and health-related business, not-for-profit, and governmental organizations.

Other considerations

Prospective doctoral students should consider several other factors when contemplating a terminal degree. Although time and cost may be primary considerations, NPs should evaluate circumstances surrounding their personal lives and individual goals. For instance, a spouse, children, and job demands can influence the decision to start a doctoral program. However, with self-evaluation and an understanding and encouraging support system, NPs pursuing doctoral education can thrive and adequately balance all aspects of their lives.

Another consideration is an individual’s learning needs and preferences. A doctoral program with classes offered solely at a university campus may benefit certain students, whereas others may be more successful with an exclusively online program. A program with live classes allows for in-person communication with professors and classmates, and can facilitate communication on an interdisciplinary level as well. NPs considering an online format will want to explore how professor and peer interaction is fostered through distance modalities. A major plus of an online program is that it can provide more flexibility with regard to a student’s work and family obligations. Hybrid programs with both live and online components are also widely available, and often provide some balance between the advantages and disadvantages of each.

Prospective doctoral students should examine a variety of schools for program format, curriculum requirements, and faculty expertise. Open houses and conferences offer multiple opportunities to learn more about various programs and ask questions to help determine the best path for each student. Once a student decides on pursuing a doctorate degree to become a researcher, clinician, or educator, finding a mentor already in the selected role can provide valuable guidance throughout the instruction and training process. In addition, NPs should explore part- and full-time option availability and accreditation status before choosing a program. AACN lists the main differences between the PhD and DNP degrees. In addition, AACN has compiled a list of Commission on Collegiate Nursing Education (CCNE)-accredited DNP programs with links to various schools’ websites (organized by state). Furthermore, AACN provides a comprehensive list of PhD and EdD programs with more detailed school and contact information. With regard to DNP programs, they should be both regionally and nationally accredited in order for students to obtain recognition for title and job purposes after graduation. The quality of a doctoral program can enhance the student experience and influence potential employers at the completion of the degree.

Conclusion

Nurse practitioners with doctoral degrees are needed in academic and patient education, research, health policy, and QI efforts. Many factors should be considered when choosing among options for doctoral degrees. NPs with a variety of doctoral degrees can complement each other and work together to further nursing education, implement changes, and favorably affect patient care outcomes.

Cathy R. Kessenich is Professor of Nursing and Department of Nursing Director at the University of Tampa in Tampa, Florida. Sasha T. Persaud works in pediatrics and is an MSN student and former graduate assistant in the nursing department at the University of Tampa. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Fortier ME. So you want to get a doctorate. Am Nurse Today. 2013;8(5):41-44.

2. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. 2010.

3. American Association of Colleges of Nursing. The Research-Focused Doctoral Program in Nursing: Pathways to Excellence. 2010.

4. Nardi DA, Gyurko CC. The global nursing faculty shortage: status and solutions for change. J Nurs Scholar. 2013;45(3):317-326.

5. Melnyk BM. Distinguishing the preparation and roles of doctor of philosophy and doctor of nursing practice graduates: national implications for academic curricula and health care systems. J Nurs Educ. 2013;52(8):442-448.

6. Dreher HM, Glasgow MES, Cornelius FH, Bhattacharya A. A report on a national study of doctoral nursing faculty. Nurs Clin North Am. 2012;47(4):435-453.

7. McDermid F, Peters K, Jackson D, Daly J. Factors contributing to the shortage of nurse faculty: a review of the literature. Nurs Educ Today. 2012;32(5):565-569.

8. Duke University School of Nursing PhD Program.

9. Moore K. How DNP and PhD nurses can collaborate to maximize patient care. Am Nurse Today. 2014;9(1):48-49.

10. Dunbar-Jacob J, Nativio DG, Khalil H. Impact of doctor of nursing practice education in shaping health care systems for the future. J Nurs Educ. 2013;52(8):423-427.

11. Grey M. The doctor of nursing practice: defining the next steps. J Nurs Educ. 2013;52(8):462-465.

12. American Association of Colleges of Nursing. The Doctor of Nursing Practice: Current Issues and Clarifying Recommendations: Report from the Task Force on the Implementation of the DNP. August 2015.

13. Stoeckel P, Kruschke C. Practicing DNPs’ perceptions of the DNP. Clin Schol Rev. 2013;6(2):91-97.

14. Evans JD. Factors influencing recruitment and retention of nurse educators reported by current nurse faculty. J Prof Nurs. 2013;29(1):11-20.