February 22, 2018

On Zika Preparedness And Response, The US Gets A Failing Grade


There are worrying signs that the United States is unprepared to contain a likely Zika virus outbreak this summer. The critical problems are: insufficient resources for mosquito control, surveillance, and health care; highly variable capabilities and quality of service among public health and mosquito abatement authorities; and weak legal powers to implement critical interventions.

The Pan American Health Organization (PAHO) reports that 35 countries and territories in the Americas have confirmed local, vector-borne transmission of Zika since 2015. In the US, local mosquito-borne transmission has been reported in Puerto Rico, the US Virgin Islands, and American Samoa. Puerto Rico, in particular, is experiencing a frightening epidemic, and with travel to and from that island and the wider region—and with the Rio Olympics looming—the conditions are ripe for spread into the continental US.

On April 13, Centers for Disease Control and Prevention (CDC) concluded that a scientific consensus exists that the Zika virus causes neurological deficits in newborns including microcephaly. The World Health Organization (WHO) has concluded that a scientific consensus exists that Zika virus also causes Guillain-Barré Syndrome — a disorder in which the body’s immune system attacks the peripheral nervous system. Scientists also expect that clusters of Zika virus outbreaks will occur this summer in the continental United States, principally in Florida and the Gulf Coast states, but with the potential to affect up to 30 states, as far north as Washington, DC, Philadelphia, and New York City. Pregnant women, particularly those in lower socioeconomic status groups in the southern US, are at heightened risk. Yet, Congress has thus far refused to pass President Obama’s supplemental $1.86 billion funding request to buttress Zika preparedness.

It is one thing to fail to prepare for an emerging infectious disease if the risks are uncertain. But it is quite another to fail to act when the facts are clear: we know that Zika is coming to the US, that it harms newborns, and will disproportionately affect poor women and their children. Failure to prepare for a storm that is spreading rapidly in our region, heading for our shores, and which could affect the next generation is unconscionable. It is also a major political mistake. Imagine if nine months following a Zika virus outbreak this summer babies are born with severe birth defects, and poor women testify in Congress holding their babies. It would, and should, result in a public moral outrage.

Congress Fails To Fund Zika Preparedness

In February, the Obama Administration submitted an emergency supplemental appropriations request of $1.86 billion to the House of Representatives to respond to the Zika virus domestically and internationally. The vast majority of the funding request, $1.48 billion, would be directed to the Department of Health and Human Services — $828 million of which would go to the CDC. The funding includes $200 million to support vaccine development through to commercialization with the National Institutes of Health being the lead agency.

The United States Agency for International Development (USAID) would receive $335 million for targeted activities in South America, Central America, and the Caribbean. Finally, $41 million would be directed to the Department of State to inter alia support WHO, PAHO, and UNICEF public health efforts to address the Zika virus in affected countries while ensuring health security in the United States. This funding is essential to ensure that the federal government, states, and localities have the resources needed to prepare and respond to a likely Zika virus outbreak.

It is now two months later and Congress continues to delay the approval of the Obama Administration’s Zika supplemental funding request. The seriousness and immediacy of the situation was highlighted on April 6, 2016 with the White House redirecting $589 million from already allocated Ebola funds to the Zika response. While it may seem appealing to use money previously allocated to the Ebola outbreak, it breaks America’s promise to West Africa, which is still reporting Ebola cases; and it risks making the US population more vulnerable to infectious disease threats as funds are shifted from other priorities. In order to directly support Zika preparedness and response activities, on March 22, 2016 the CDC announced a reduction of $44.25 million in state emergency preparedness funding provided under the Public Health Emergency Preparedness (PHEP) cooperative agreement, which would cut annual preparedness funding to the states by up to 10 percent under the PHEP cooperative agreement for the fiscal year commencing July 1, 2016.

This redirection could have significant public health consequences, impeding the capacity of state and local health officials to fully implement Zika preparedness and response plans. The Association of State and Territorial Health Officials has expressed grave concern, calling on Congress to approve the Administration’s Zika funding request.

Variable Capabilities And Weak Legal Powers

Vector control—that is containing and eliminating the mosquitoes that carry and spread the Zika virus—remains the primary legal responsibility of state and local governments, resulting in considerable variability in the resourcing, expertise, and powers to achieve the goal. While federal agencies cannot assert legal authority over states or localities, they can provide funding, scientific guidelines, and technical assistance.

At the same time that the CDC has had to cut back on state funding, states themselves have often failed to invest in mosquito control, surveillance, and other preparedness activities. There exists a patchwork quilt of more than 700 mosquito control districts — some within local health agencies and others within departments of agriculture, transportation, or parks. Most US localities do not even fall within existing mosquito control districts, leading to highly divergent practices. For example, Miami-Dade County reports significant underfunding for its abatement efforts. Other smaller jurisdictions can do little more than advise inhabitants to use over-the-counter insect repellents.

Although several states and localities are repurposing West Nile Virus powers to tackle Zika, many laws are weak or unclear. Federal and state regulations often make it difficult to implement rapid and effective mosquito control interventions — which are often controversial. Spraying habitats and neighborhoods can require special permissions; entering private property to remove standing water and other mosquito breeding areas often can be blocked by the home owner; and the Environmental Protection Agency must approve the dissemination of genetically modified mosquitoes that can vastly reduce disease-causing mosquito species.

This maze of regulation can impede essential activities, but there is also the potential for politicians to overreact. Recalling the counterproductive use of travel restrictions and quarantines during Ebola, there are already discussions among conservative politicians for similar measures for Zika, which would lack any scientific rationale.

Future Prospects

The increasing urgency of responding to an emerging Zika virus outbreak led the Obama Administration to update its supplemental funding request to Congress on Monday April 18, 2016. The update reallocates an additional $147 million in research funding, including vaccine research, as well as $88 million for the Biomedical Advanced Research and Development Authority for vaccines and diagnostic tests.

However, this is not new money; rather, those increases would be covered by a reduction in the amount requested for an unallocated contingency fund for emerging threats. Appropriations are constitutionally required to begin in the House, but there are bipartisan efforts in the Senate to bypass the stalemate. Yet, as Zika looms as a serious threat to the homeland, and as science is proving that Zika causes grave harms to newborns, Congress continues to shut its eyes and close its pocket book.

This is more than simply a public health issue, but also a matter of social justice threatening the poorest people in our country. Congress must not ignore the ethical and moral implications of its delay while federal, state, and local public health agencies struggle without the critical funding needed to protect the health of poor Americans.

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