Mosquitos that may carry the Zika virus pose a serious health concern. Zika virus disease (Zika), a disease caused by Zika virus, was first discovered in 1947 in Uganda. This virus is spread to people primarily through the bite of infected Aedes species mosquitoes, and these mosquitoes have caused outbreaks in tropical Africa, Southeast Asia, and the Pacific Islands through the latter half of the 1900s. In addition, more recent evidence indicates that Zika can also be spread during sex by a man infected with Zika to his partners and has the potential to spread if blood supplies are contaminated by infected donors. Prior to the current outbreak of Zika, which was detected in May 2015 in Brazil, there had not been widespread Zika transmission in the Americas. On February 1, 2016, the World Health Organization declared a Public Health Emergency of International Concern due to clusters of microcephaly in newborns and other neurologic disorders. Zika continues to spread and is now present in more than 30 countries. Fortunately, as of early May, there have been no locally acquired cases of Zika in the continental United States. However, there have been more than 400 travel-associated ("imported") cases, with most states having at least 1 case. Conversely, the US Insular jurisdictions such as American Samoa, Puerto Rico, and US Virgin Islands, and most recently Micronesia (Kosrae), are experiencing local transmission in excess of 300 cases combined, with Puerto Rico experiencing widespread transmission across the island, with only a handful of travel-associated cases reported. While experts are not able to predict when and how much Zika will spread in the continental United States, public health officials' concerns are escalating as we enter mosquito season and the vector becomes more active in the spring and summer months. In addition, some populations may be more vulnerable to exposure through mosquito bites including those who live in crowded conditions or who have living conditions that do not provide basic protection measures from mosquito bites such as air-conditioning or properly screened windows. Even if we only experience sporadic clusters of limited infection, the clear and present danger presented by Zika warrants an immediate and coordinated response nonetheless.
More than half of the United States, mostly in the south and east, have the Aedes mosquito within their borders, either Aedes aegypti (species of primary concern) or Aedes albopictus (of lesser concern), or both, and, therefore, have the potential for local transmission of the Zika virus. The most common symptoms of Zika infection are fever, rash, joint pain, and conjunctivitis and are usually relatively mild. The vast majority of people infected with Zika virus will not know they have the disease because they will not have symptoms. What makes Zika so much of a public health threat is that it is a cause of microcephaly and other severe fetal brain defects, as determined by the Centers for Disease Control and Prevention (CDC). Because of these potential birth outcomes that have devastating and permanent effects, the United States is facing a somewhat unpredictable and unprecedented threat requiring a whole of society response with strong leadership at all levels and a forward-thinking and forward-leaning posture. The duration of our response will not be measured in days, weeks, or months, but rather in years. Response efforts will also need to be concerted and will require expanded partnerships in areas not typically seen in other types of emergencies, that being vector surveillance and control, and reproductive, maternal, and child health services.
The main objective is to prevent Zika infection in pregnant women to prevent Zika-related birth defects. To accomplish this, health agencies are standing up incident management systems and developing risk-based Zika Action Plans, aided by the Zika Action Planning Summit hosted by CDC on April 1, and are enhancing disease surveillance and epidemiologic investigations to monitor and report new cases of Zika and to learn about disease transmission patterns, using new laboratory testing methods for rapid diagnosis of infection, focusing mosquito surveillance and control on the competent vectors of concern, preparing to support the newly created US Zika Pregnancy Registry, working with community clinicians and maternal and child health specialists to prepare to address the impending medical and emotional health needs of cases and their families, and clearly and appropriately communicating the risks and educating the public on preventive steps that can be taken to avoid infection.
Every crisis response requires the public health system to mobilize assets, deploy personnel, and interact with existing, as well as new, partners. With each response, we are cultivating a more agile, experienced, and skilled public health system and the public is greatly served by the commitment and dedication of the public health workforce. The most formidable challenge the system faces, however, is the lack of sufficient, sustainable, and scalable resources to support the infrastructure necessary to effectively deal with "everyday" emergencies, as well as those that are major, sometimes, potentially catastrophic. The basic public health infrastructure has eroded because of lack of funding in recent years and, as a result, we are more vulnerable. To illustrate this point:
* Funding levels of the CDC Public Health Emergency Preparedness (PHEP) Cooperative Agreement has diminished through the years. While there have been some recent increases, it is still down about $70 million from 2010 (the FY 16 Appropriation was $660 million).
* The Association of State and Territorial Health Officials (ASTHO) and the National Association of County & City Health Officials tracked job losses from the onset of the Great Recession in 2008 to 2014. During that time, more than 51 000 state and local public health jobs were lost, representing more than 19% of the state and local health department workforce.
* A press release issued by the Council of State and Territorial Epidemiologists1 on February 8, 2016, describes how the national arboviral surveillance infrastructure built for West Nile virus response was compromised by a 61% decrease in Epidemiology and Laboratory Capacity grant funding from 2004 to 2012 resulting in 67% of national jurisdictions having decreased mosquito trap sites, a 70% decrease in mosquito pools tested, and a 45% decreased testing on humans. Furthermore, the press release reports only 62% of jurisdictions in 2012 had a formal plan for killing adult mosquitoes in the event of an outbreak.2
Trust for America's Health has recommended that all levels of public health (federal, state, and local) receive adequate and predictable funding to maintain a core set of public health capabilities along with developing coordination between health care facilities and public health agencies. In addition, a cochair of the Blue Ribbon Study Panel on Biodefense indicated:
We must address the root causes underlying the frequent emergence of infections like Zika, and we must also build preparedness for them into existing budgets. Governing by the billions on an emergency basis for the now predictable problem of emerging infections is tactically inefficient, financially untenable, and potentially costly in human lives.3
As was previously done with the H1N1 influenza pandemic and the Ebola outbreak, in early February 2016, the White House submitted a request for $1.9 billion in emergency supplemental funding for a wide range of critical Zika-related preparedness and response activities, both domestic and international, including state and local readiness and response, enhanced mosquito control, improved surveillance and diagnostics, public education strategies, applied research, and vaccine development. As of May 1, 2016, Congress had not yet acted on this request, as some members of Congress are questioning whether the resources provided less than 2 years ago for Ebola preparedness and response could be used for Zika-related activities.
Faced with this pending action and the need to make difficult decisions regarding priority allocation of available resources, CDC announced on March 16, 2016, that it was redirecting $44.25 million from the PHEP cooperative agreement for the upcoming budget period beginning July 1 to immediately support Zika activities. This represents a reduction of about 7% of the total annual amount in the next round of PHEP funding to states, territories, and the 4 directly funded cities (New York; Los Angeles; Chicago; and Washington, District of Columbia). This action was followed by a White House announcement on April 6 that stated the Administration identified $589 million, including $510 million of existing Ebola resources, that can be redirected for immediate critical Zika activities as a stopgap measure, while reinforcing the need for the full emergency supplemental request that would also replenish the Ebola and other funds that were tapped.
These events clearly demonstrate the need to (1) overcome complacency and reinvest in foundational public health preparedness and response capacity and capabilities, (2) provide additional resources to support scaled up and expanded responses to public health emergencies, especially those that are very complex such as Zika, without "robbing Peter to pay Paul," and (3) have mechanisms in place to provide resources when needed so that precious preparedness and response time is not lost.
To this end, ASTHO and many of its partners, as evidenced by 2 letters* sent to Congressional leadership with dozens of cosignatories, support the prompt passage and immediate programming of the $1.9 billion Zika emergency supplemental funding request, with replenishment of accounts previously tapped to support Zika activities. ASTHO also supports:
1. Increasing annual core state, local, territorial, and tribal public health emergency preparedness funding made possible through PHEP and other proven cooperative agreement programs such as CDC's Epidemiology and Laboratory Capacity Program and the HHS/ASPR Hospital Preparedness Program.
2. Creating a special Public Health Emergency Reserve Fund, similar to the one administered by the Federal Emergency Management Agency for Stafford Act-related disasters, that will serve as a mechanism for the expedited release of additional funds to impacted jurisdictions to support mission-critical response activities to mitigate the impacts of future public health emergencies or disasters.
Zika is likely to reach the US mainland in the coming months. In a CDC press release, Dr Tom Frieden, CDC Director, stated that "everyone has a role to play. With federal support, state and local leaders and their community partners will develop a comprehensive action plan to fight Zika in their communities."4 Protecting pregnant women and others from becoming infected with Zika will take action from our entire nation. Individual citizens can help by eliminating mosquito breeding sites such as standing water on their properties. Federal policy makers will need to act swiftly to make the necessary investments for a more robust and resilient public health system to execute Zika Action Plans and the plans that will be inevitably developed for future threats to prevent illness and suffering and save lives.
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