Cover Story — August 2016
Tex Med. 2016;112(8):24-31.
By Joey Berlin
The public health catastrophe that many feared had yet to hit the United States in the early days of summer, but with potential carriers of that catastrophe soaring, buzzing, and biting all over Texas, state officials and physicians plowed ahead with confronting the inevitable. Even without a single known case of local transmission of Zika virus disease in the United States, the mosquito-borne illness was already looming large in the nation's health care sphere this spring and summer as outbreaks spread in South America, Central America, the Caribbean, and the Pacific Islands.
At a Texas Children's Hospital infectious disease pregnancy clinic in Houston, Catherine Eppes, MD, says she saw a spike in interest in screening for Zika as more news about the disease, which carries particularly dangerous implications for fetuses, emerged.
"Initially, we just had a couple of patients coming in who had travel history to areas where Zika was endemic," said Dr. Eppes, a member of the Texas Medical Association's Committee on Infectious Diseases. "[But] in the last couple of months, pregnant women possibly exposed to Zika virus have become the largest volume of patients that we're seeing in that clinic. This includes physician referrals and individual patients seeking guidance and referring themselves. I'm definitely seeing more and more patients coming either for an ultrasound or just general prenatal care asking about Zika, even those who have no travel experience whatsoever."
The concern over Zika rested largely in the potential for pregnant mothers to spread the disease to their children, who can then develop birth defects such as microcephaly, which often indicates a smaller, underdeveloped brain.
As Zika became a recognized threat to the United States at the dawn of 2016, Texas scrambled to coordinate a prevention-and-response strategy to what seemed a foregone conclusion: local transmission of the virus. Meanwhile, TMA urged lawmakers in Washington, D.C., to agree on a funding package for Zika, with TMA President Don Read, MD, saying the state’s public health officials needed that support.
Texas Department of State Health Services (DSHS) Commissioner John Hellerstedt, MD, said in June that preparing for Zika was difficult because no one knew how big a problem it would pose.
"In a sense, something like a hurricane is easier to plan for," he said. "They're smaller in size, but in general, as they're coming at you, you know where they're going to hit and what kind of damage they're capable of inflicting, to some degree. And you try and move people out of the way. That kind of quantitative information about the scope of Zika and its potential for Texas is just not knowable."
Knowns and Unknowns
Although human cases of the Zika virus first emerged in Africa more than 60 years ago, and the first large human outbreak occurred on a Micronesian island in 2007, the U.S. Centers for Disease Control and Prevention (CDC) was still learning new information and adjusting its guidance on the disease as it examined the threat this summer.
Along with microcephaly, other problems that have been found in infants infected with Zika include eye defects, hearing loss, and growth impairment. CDC also was investigating the link between Zika and Guillain-Barré syndrome, in which a person's immune system attacks nerve cells, causing muscle weaknesses and possible paralysis.
Humans primarily contract Zika through the bite of an Aedes species mosquito, either Aedes aegypti or Aedes albopictus, according to CDC. Those species can also transmit two other noted viruses: dengue fever and chikungunya. Although both species are present in Texas, the Aedes aegypti species is the one most likely to spread Zika and other viruses, according to CDC. Modeling from the National Center for Atmospheric Research Geographic Information Systems program projected the Houston and Brownsville areas to have the greatest abundance of Aedes aegypti in July. (See "Zika Hot Spots.")
Umair Shah, MD, executive director of Harris County Public Health, says the tendencies of the Aedes aegypti mosquito make personal protection measures, such as wearing long clothing, applying mosquito repellent, and draining excess water out of yards, particularly important. Aedes aegypti typically lay eggs in and near standing water.
"A lot of people call Aedes aegypti the cockroach of mosquitoes. It finds its way of getting into small breeding areas of water and then essentially propagates," said Dr. Shah, a member of the TMA Committee on Infectious Diseases. "And that is a big challenge with this mosquito. It doesn't require a lot of water to grow. It likes predominantly the human as its primary target, so even if there's a dog or a cat nearby, it's going to go for the human. It's adapted to be an urban mosquito; it likes to live near humans and close to homes and all those kind of things."
CDC says most people with Zika virus won't show symptoms and won't even know they have the disease. According to CDC, the most common symptoms include fever, rash, joint pain, and conjunctivitis. Muscle pain and headache are also common. CDC says the disease's incubation period is most likely a few days to a week. Zika usually remains in an infected person's blood for about a week. Its symptoms are similar to dengue and chikungunya.
Among other recommendations, CDC advises people who have Zika to get rest, drink fluids, and avoid mosquito bites for the first week of illness because a mosquito could potentially get the disease from an infected person.
Health agency recommendations for Zika were fluid in June as officials learned more. In late May, for example, the World Health Organization (WHO) recommended couples living in or returning from areas infested with Zika wait at least eight weeks before trying to conceive. That's twice as long as the previously recommended four weeks.
One evolving area of study was the extent to which Zika remains a sexually transmitted disease. A man with Zika can pass the disease to his sex partners; the first known sexually transmitted case in humans occurred in 2008, according to WHO. In cases CDC was aware of, men who passed Zika sexually had shown symptoms and could pass the disease before, during, or after exhibiting those symptoms. The virus can stay in semen longer than in blood, but CDC didn't know exactly how long it remains in semen.
Health officials and researchers did not know at press time whether females with Zika could pass the disease sexually to their partners.
CDC said there was a "strong possibility" Zika can be transmitted by blood transfusion, although the United States hadn't seen any such cases at press time. Reports of transmission by blood transfusion in Brazil were under investigation, the agency said. For more information on Zika transmission, symptoms, and risks, visit the CDC website.
At press time, there had been 55 cases of Zika virus disease in Texas; CDC had reported 1,133 nationally.
Dr. Hellerstedt says the public can start preparing now for the eventual local transmission of Zika. Preventive steps include removing standing water from yards, wearing mosquito repellent, and putting up screens, he says.
"I think the intensification of what we do and the targeting of what we do in terms of looking at a particular geographic area where there may be local transmission of Zika, that's the part that will change. But what I hope will happen is that any kind of evidence of local transmission will only be a further call to action for the rest of the state, for everyone else to keep doing those other things more intensely and more observantly. And that's going to give us the best chance. Even if we have isolated pockets of Zika transmission, they'll die out over a period of time."
DSHS has a Zika website for the public. The site includes a page with guidance and links specifically for health care professionals. (See "Physicians and Zika.")
"When a patient comes to a clinic to see a physician, it's really important for the physician to be able to ask the relevant questions and be as astute as possible clinically in order to be able to find the needle in the haystack of the patient who has Zika," Dr. Shah said. "Physicians have to ask questions about travel, have to ask questions about [whether there's] been sexual contact with the traveler to a Zika-affected area, and a number of questions that really at the end of the day drive home the point that that frontline physician is the key member of that health response."
Medicine took swift action in the Lone Star State to prevent and preempt the emergence of Zika. For example, Texas Children's opened a Zika-specific clinic where women can discuss their risk factors with Dr. Eppes and other physicians and receive Zika testing
"We see a lot of pregnant women very concerned," Dr. Eppes said. "We've actually picked up a lot of dengue virus infections and are seeing the challenges in testing in women who have either had chikungunya or dengue, in that it makes it really hard to interpret their serologic tests for Zika."
The specter of the virus is also affecting blood donations at facilities like Gulf Coast Regional Blood Center in Houston, which Susan Rossmann, MD, says is losing donors because of the need to screen for potential Zika presence. Dr. Rossmann, the center's chief medical officer, says the center is following the U.S. Food and Drug Administration's guidance on donor screening for Zika. Under the guidance, people who have traveled to areas of known local Zika transmission shouldn't donate for four weeks following their departure. One of those areas is Mexico, which had more than 600 confirmed cases in the current outbreak. (See "Hardest-Hit Countries.")
Dr. Rossmann says the center also began an investigational clinical trial in May to test donors for the presence of Zika.
"There would be the possibility that someone could get it and feel healthy and well on the day of donation, but have Zika," Dr. Rossmann said. "We certainly just found that for West Nile, which we test, and so we wanted to investigate that possibility."
As physicians did their part to keep the disease from emerging or spreading, Dr. Read and TMA were part of the effort to prod a gridlocked Congress into settling on a funding agreement to anticipate a potential Zika epidemic.
Dr. Read knows firsthand the havoc a mosquito-borne illness can wreak on the human body. He contracted West Nile virus in 2005, and its devastating effects sidelined him from work for seven months. When he first went back to work, he could see patients for an hour per day before he had to return home and go back to bed. It took about a year before he could work a full schedule again.
"My arms were paralyzed. My legs were paralyzed. I couldn't talk. I couldn't hear. I couldn't write. I was sleeping 23-and-a-half hours a day, and my legs hurt like hell," he said. "It was impressive. I, fortunately, didn't go into a coma; I think the only reason I didn't is because my family was there 24 hours a day punching me and waking me periodically."
In a letter to the Texas congressional delegation in May, Dr. Read referenced his own experience with West Nile. He wrote it was only a matter of time before a mosquito bites a traveler who brought Zika to the United States before passing it on to another Texan.
"Local and state public health officers in Texas are working hard to prepare for that day, but we need help," he wrote. "We have the experience and expertise necessary, but our public health infrastructure is not up to a task of this magnitude."
In late May, the American Medical Association wrote House Speaker Paul Ryan (R-Wisc.) urging Congress to take immediate action on the Zika threat. In the letter, James L. Madara, MD, AMA executive vice president and chief executive officer, noted the link between prenatal Zika and microcephaly, as well as other abnormalities. Dr. Madara also noted the growing evidence linking Zika to Guillain-Barré syndrome.
"Time is growing short to make the critical investments that all agree are necessary to prevent local vector-borne transmission of the Zika virus and the potential health impacts of infection," Dr. Madara wrote.
At press time, Congress had not settled on a funding package.
Dr. Read's letter to the Texas delegation mentioned the recent reduction Texas has suffered in federal public health emergency preparedness funding, including a cut of nearly $4 million for 2016–17.
"The problem with public health is this: When we have a disaster like Ebola, then all of a sudden the next year they'll put a bunch of money into public health. If nothing happens for a year or two, they say, 'Oh well, see, we didn't need to spend all that money. Nothing's happening,' so then they defund public health," Dr. Read said. "And then the next big thing comes along, which we have trouble dealing with because public health is underfunded. It just goes in cycles over and over and over like that."
In mid-June, Gov. Greg Abbott wrote to CDC inviting the agency to review the DSHS Zika plan. The state had applied for three grants from CDC totaling about $11 million, including $9.2 million to strengthen epidemiology and laboratory capacity and improve health information systems; $1.5 million to support preparedness and response; and $360,000 to support surveillance of Zika-related birth outcomes.
Dr. Hellerstedt says federal funding would allow state and local officials to bolster every aspect of their Zika response.
"We'd be confident that we have additional vector control resources, for example," he said. "But the converse of that is, it is something that is literally in people's backyards, so individuals can already take and play an enormous role in delaying or denying or vastly limiting the extent of threat that we might experience in Texas."
Working on a Strategy
In a state where the response to an epidemic often begins with local authorities, DSHS was working to centralize the Zika response by drafting its own plan of action to deal with the threat, involving coordination with local public health agencies.
"In my opinion, it's not all about hardware and hiring professionals to go out and spray," Dr. Hellerstedt said. "A lot of it is leadership and getting out into communities and faith-based organizations, service organizations in those communities, to get out there and help their neighbors … and make people aware of just how powerful and effective these very simple measures are that they can undertake."
Harris County Public Health, known for its proficiency at mosquito surveillance and control, funds 98 percent of its mosquito control program with local money, Dr. Shah says.
"Local health authorities really have the key role because we understand our community," he said. "We know the nuances of our health care system. We know what the political considerations are within our community. We know who the partners are. We know the strengths and limitations of communication modalities in our own community."
Dr. Shah adds the state plays an important role by "supporting the activities that the locals are engaged in."
Sen. Charles Schwertner, MD (R-Georgetown), chair of the Senate Committee on Health and Human Services, says the response to a Dallas-area nurse contracting Ebola from a patient in 2014 showed that local health departments and medical facilities need help and leadership from the state to deal with public threats. After the Ebola scare, Senator Schwertner introduced Senate Bill 538 during the 2015 legislative session.
SB 538 sought to provide the governor authority to declare a state of infectious disease emergency upon consultation with the DSHS commissioner and the state's Division of Emergency Management if the governor sees a "serious and imminent risk" to the state.
That would have given the DSHS commissioner "authority for all state and local public health policy decisions, procedures, and disease control measures necessary to contain the infectious disease emergency." The bill passed the Senate but stalled in a House committee. Senator Schwertner says SB 538 would have allowed "a more centralized command structure" to deal with infectious diseases.
"One of the issues we saw up in Dallas was [that] there were a lot of potential bosses — everything from CDC individuals to the county judge to the local health director to [then-Commissioner] Dr. [David] Lakey and the Department of State Health Services to the hospital management, which was actually in charge of calling the shots on a minute-by-minute basis," he said. "We do need that better coordination and communication among all the various levels of government: federal, state, and local."
With the DSHS Zika draft plan, Senator Schwertner said, "We're trying to raise their awareness and raise that coordination and communication, but not take control or supervision away from the local health departments. Rather, [we're trying to] facilitate their understanding of it and increase the surveillance and abatement and control procedures that they have at the local level and hopefully coordinate that between the various health districts."
He says whether local authorities take the lead should depend on the health threat at hand.
"Infectious diseases don't stop at county borders or municipality borders, and then each county is different as far as their preparedness and ability to confront various threats," Senator Schwertner said. "In the case of the Zika virus, Harris County is probably the most prepared regarding mosquito control abatement and surveillance that we have in the nation. Certainly here in Texas, it's the most prepared. But even it can get overwhelmed. How do we make sure these counties are best prepared and facilitate the help that some counties that are less prepared might need? They have their own organization associations, but I do think there's a role for the state to play in severe outbreaks that overwhelm local resources."
Dr. Hellerstedt says the level of cooperation between state and local health authorities has been good, with conversations between the two about how to coordinate a response in the event of an outbreak.
"The fascinating thing to me about the Zika menace, if you will, is that the weapons we have to fight it are really very simple and straightforward and also very effective," he said. "But simple, straightforward, and effective doesn't necessarily translate into easy. What it requires is lots of people undertaking those kind of preventive measures. From that extent, that's where the communication and cooperation at all levels of the response is important.
"From my standpoint, for instance, CDC is going to be the source of scientific knowledge about Zika and its effects and its biology and that sort of thing. I think the local health departments and local counties in Texas … those folks, we will coordinate with them and assist them as our resources allow us to do. Their communities are the ones that are going to need to be the first folks to take action."
Dr. Hellerstedt is the director of the Governor's Infectious Disease Task Force, a 31-member body Governor Abbott appointed in February to assess infectious diseases and develop protocols and recommendations. TMA formed its own Zika workgroup in June, with members from TMA boards, councils, and committees.
At the federal level, CDC has established the U.S. Zika Pregnancy Registry to collect information about pregnancy and infant outcomes when laboratory evidence points to infection with the virus during pregnancy.
Why Texas Is Different
Dr. Hellerstedt says although Zika is a disease with devastating implications for unborn children, people in the United States and Texas living in fear of the virus need a clearer perspective on the risk it poses.
"I think that's important because my biggest concern is essentially public reaction to this, where if there is local transmission in a very isolated area, suddenly people all over the state think they're at risk for acquiring the disease, and that will not be the case," he said.
The socioeconomic conditions in Texas, Dr. Hellerstedt says, are vastly different from those in other countries where Zika has been prevalent. He says regions of Brazil and Puerto Rico that have experienced outbreaks feature many people living close to one another in warm and humid conditions, with many sources of water, no air conditioning, no screens, and no mosquito repellent in use. Along those lines, Dr. Hellerstedt also notes dengue fever is much more prevalent across the border in Mexico than it is in Texas or the rest of the United States, where cases are rare.
"Even though we have pockets in the United States where arguably you could say, 'We have poor people here, and they don't have screens, and they don't have air conditioning,' we don't have whole metropolitan areas that are like that the way they do in Brazil," he said. "Just the fact that we've got that stark contrast in socioeconomic conditions between the two countries is very important. I hope that CDC will begin to lead, for instance, in trying to get that message across to the public. Yes, Zika's very scary in terms of what it can do, but also the chances that it will overwhelm communities in the United States the way it has overwhelmed communities in Brazil — there's lots of reasons to believe that will not happen. And I think that's very important in the context of how we respond to it in the United States because I think people just need to have a more proportionate notion of what the risk really is."
The message Harris County has been sending both to the community at large and the health care community, Dr. Shah says, is "prevent and present." Whether at home or abroad, people should work to not get Zika in the first place. "Fortunately, we don't have mosquitoes here with Zika, but it's a matter of time," he said.
Dr. Eppes says lawmakers should realize the catastrophic impact of Zika. During testimony to the state Senate Health and Human Services Committee in May, she stressed the need for expanded screening for the disease.
"Not being able to prevent the virus, offer vaccination, or treat it once women have gotten Zika really makes all of the focus needing to be on preventing exposure, and … that means we have to do the majority of the hardest work now," Dr. Eppes said. "I think it is also important to expand testing capabilities because if Zika does become endemic in the United States, there's going to be such a high volume of testing. We do not have that testing capability right now."
Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.
Physicians and Zika
The Texas Department of State Health Services' Zika virus disease website features information for the general public on the disease and also includes tools for physicians and other health care professionals who care for women of reproductive age and for infants and children who may have been exposed to Zika. The information draws from U.S. Centers for Disease Control and Prevention (CDC) interim Zika virus guidance.
CDC has these recommendations:
- Conception: Women who have Zika should wait at least eight weeks after the onset of symptoms to attempt conception. Men who have the virus should wait at least six months to attempt conception. People residing in areas of active transmission of the virus should talk to health care professionals about attempting conception.
- Pregnancy: For pregnant women living in areas with ongoing Zika virus transmission, CDC recommends testing at the beginning of prenatal care and follow-up testing around the middle of the second trimester. For pregnant women with symptoms consistent with Zika, CDC recommends testing at the time of illness.
- Infants: CDC recommends testing for infants born with microcephaly or intracranial calcifications whose mothers traveled to or resided in a Zika transmission area while pregnant, and testing for infants born to mothers with positive or inconclusive Zika test results. Pediatricians should work closely with obstetricians to identify infants whose mothers may have been infected with Zika during pregnancy and should review fetal ultrasounds and maternal testing for the virus.
For more information and resource links, visit the Texas Department of State Health Services website.
For more information about Zika virus, visit these websites:
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