PT  - JOURNAL ARTICLE
AU  - Nathan D. Grubaugh
AU  - Sharada Saraf
AU  - Karthik Gangavarapu
AU  - Alexander Watts
AU  - Amanda L. Tan
AU  - Rachel J. Oidtman
AU  - Jason T. Ladner
AU  - Glenn Oliveira
AU  - Nathaniel L. Matteson
AU  - Moritz U.G. Kraemer
AU  - Chantal B.F. Vogels
AU  - Aaron Hentoff
AU  - Deepit Bhatia
AU  - Danielle Stanek
AU  - Blake Scott
AU  - Vanessa Landis
AU  - Ian Stryker
AU  - Marshall R. Cone
AU  - Edgar W. Kopp IV
AU  - Andrew C. Cannons
AU  - Lea Heberlein-Larson
AU  - Stephen White
AU  - Leah D. Gillis
AU  - Michael J. Ricciardi
AU  - Jaclyn Kwal
AU  - Paola K. Lichtenberger
AU  - Diogo M. Magnani
AU  - David I. Watkins
AU  - Gustavo Palacios
AU  - Davidson H. Hamer
AU  - for the GeoSentinel Surveillance Network
AU  - Lauren M. Gardner
AU  - T. Alex Perkins
AU  - Guy Baele
AU  - Kamran Khan
AU  - Andrea Morrison
AU  - Sharon Isern
AU  - Scott F. Michael
AU  - Kristian G. Andersen
TI  - International travelers and genomics uncover a ‘hidden’ Zika outbreak
AID  - 10.1101/496901
DP  - 2018 Jan 01
TA  - bioRxiv
PG  - 496901
4099  - http://biorxiv.org/content/early/2018/12/14/496901.1.short
4100  - http://biorxiv.org/content/early/2018/12/14/496901.1.full
AB  - The ongoing Zika epidemic in the Americas has challenged public health surveillance, response, and control systems. Even as the epidemic appears to be near its end in the Americas, it is unclear whether substantial Zika virus transmission may still be ongoing. This issue is exacerbated by large discrepancies in local case reporting and significant delays in detecting outbreaks due to surveillance gaps. To uncover locations with lingering outbreaks in the Americas, we investigated travel-associated Zika cases diagnosed in the United States and Europe to identify signatures of transmission dynamics that were not captured by local reporting. We found that a large and unreported Zika outbreak occurred in Cuba during 2017, a year after peak transmission in neighboring countries, with cases still appearing in 2018. By sequencing Zika virus from infected travelers, we show that the 2017 outbreak in Cuba was sparked by long-lived lineages of Zika virus introduced from multiple places in the Americas a year prior. Our data suggest that while aggressive mosquito control in Cuba may initially have been effective at mitigating Zika virus transmission, in the absence of vaccines, herd immunity, or strong international coordination, such control measures may need to be maintained to be effective. Our study highlights how Zika virus may still be ‘silently’ spreading in the Americas and provides a framework for more accurately understanding outbreak dynamics.