Zika Preparedness: Lessons for the U.S. Public Health System

Zika Preparedness: Lessons for the U.S. Public Health System Jeffrey Duchin, MD Health Officer, Public Health - Seattle & King County Professor in Medicine, Division of Infectious Diseases Adjunct Professor, School of Public Health University of Washington Marie Flake, MPH Special Projects, Foundational Public Health Services Washington State Department of Health www.nwcphp.org/hot-topics

Epidemiology of Zika May 11, 2016: 58 countries and territories worldwide report active Zika transmission. 2015, Brazil Zika spreads rapidly 2007, Zap Island, Micronesia 5,000 infected with Zika 1947, Uganda Zika first detected 2013-14, French Polynesia 30,000 infections

Zika Cases in the U.S. (May 11, 2016) U.S. States U.S. Territories Travel-associated cases 503 3 Locally acquired vectorborne cases 0 698 Pregnant 48 65 Sexually transmitted 10 n/a Guillain-Barré syndrome 1 5

Clinical Information Symptoms: fever, rash, joint pain, conjunctivitis (red eyes), muscle aches, headache Most cases asymptomatic or mild GBS (rare): weakness paralysis Infection in pregnant women can cause severe birth defects Fetal brain abnormalities (microcephaly) Other neurological defects

Transmission Known Theoretical Mosquito bite Intrauterine and perinatal transmission Sexual transmission Laboratory exposure Blood transfusion Organ or tissue transplantation Breast milk Fertility treatment

Aedes Egypti Mosquito Aggressive biter Lives near and in homes Multiple bites for each blood meal Found in much of the U.S.

Aedes aegypti Estimated Range, 2016 http://www.cdc.gov/zika/pdfs/zika-mosquito-maps.pdf

Aedes albopictus Estimated Range, 2016 http://www.cdc.gov/zika/pdfs/zika-mosquito-maps.pdf

Polling Question How much effort (time/resources) has the Zika outbreak response required from your organization to-date (E.g., responding to requests for testing, public and healthcare provider communication/education)? A) None to minimal B) Moderate: Requiring some diversion of resources C) Large: Requiring significant diversion of resources

Travel Advice Know health risks at your destination Avoid Zika-affected areas if pregnant Take mosquito precautions: Cover skin EPA-registered mosquito repellant Permethrin on clothing and gear A/C, screens, mosquito nets Take precautions to avoid sexual transmission from men returning from affected areas Avoid mosquito bites for 3 weeks after return from affected areas http://www.cdc.gov/travel Beatrice Murch CC BY 2.0

Responses to Possible Exposure Pregnant woman Test for Zika All Woman (asymptomatic) Woman (symptomatic) Man (asymptomatic) Man (symptomatic) Man with pregnant sex partner Anyone with 2 or more symptoms appearing within 2 weeks Wait at least 8 weeks from exposure to conceive Wait at least 8 weeks from symptom onset to conceive Abstain or condoms for at least 8 weeks Abstain or condoms for at least 6 months Abstain or condoms for duration of pregnancy Test for Zika

Sexual Transmission of Zika What We Know Zika can be transmitted by a man to his sex partners All reported cases involve sex without a condom with men who had or developed symptoms Zika can be transmitted before, during, or after presence of symptoms What We Don t Know Whether asymptomatic infected men can transmit to sex partners How long Zika persists in semen Whether infected women can transmit to sex partners Whether transmission occurs from oral sex

The Bigger Picture for Public Health Zika is one of many emerging infectious diseases. H1N1 MERS Ebola Our public health system is weakening. Uncertain, cyclical funding Total funding levels are falling Diminished workforce takes time to rebuild. Can t develop in the midst of a crisis. The CDC is not enough. We need: We have a framework to get there. State and local health departments are key. Strong skills Relationships Institutional memory Foundational Public Health Services

Foundational Public Health Services In Washington State At the national level

FPHS Overview Additional Important Services FOUNDATIONAL PUBLIC HEALTH SERVICES Foundational Programs Foundational Capabilities Communicable Disease Control Chronic Disease & Injury Prevention Environmental Public Health Maternal Child Family Health Access to Clinical Care Vital Records $380M Across all Programs Assessment (surveillance and epidemiology) Emergency preparedness and response (all hazards) Communications Policy development and support Community partnership development Business competencies

Foundational Programs Provide information Identify assets and partners, develop and implement plans Coordinate and integrate categorically-funded and other programs

A few specific governmental public health priorities are included. Communicable Disease Assure partner notification for newly diagnosed cases of syphilis, gonorrhea, HIV, active TB Chronic Disease and Injury Prevention Reduce rates of tobacco use and increase rates of healthy eating and active living Environmental Public Health Food, water recreation, drinking water, liquid and solid waste, priority zoonotics, radiation, land use planning Maternal and Child Health Taking into account the importance of Adverse Childhood Experiences (ACEs) and health disparities

A Foundation to Build On FPHS don t represent all of what public health or governmental public health does. The FPHS are basic, but they are not traditional or old fashioned. They reflect current thinking on the chief health strategist concept. FPHS provide a strong foundation from which to deliver Additional Important Services (AIS).

2014 Policy Workgroup Recommendations State Government Fund the full cost of FPHS (except for services covered by fees) Governmental Public Health Develop a comprehensive FPHS framework covering delivery, funding, and accountability Tribal Public Health Convene a process to define how FPHS will apply to tribal public health

Workgroup Recommendation: A Shift Funded by categorical grant, local or state Additional Important Services Foundational Programs Communicable Disease Control Chronic Disease & Injury Prevention Environmental Public Health Maternal Child Family Health Access to Clinical Care Vital Records FOUNDATIONAL PUBLIC HEALTH SERVICES Foundational Capabilities Across all Programs Assessment (surveillance and epidemiology) Emergency preparedness and response (all hazards) Communications Policy development and support Community partnership development Business competencies Funded by state and fees

The Path to a Comprehensive FPHS Framework Update definitions and cost / spending / gap estimates Develop funding allocation model Develop statutory language Develop service delivery options Develop accountability system

Zika Response Guidelines (Adapted from CDC) Surveillance and Epidemiological Investigation Assess and test suspect cases in collaboration with healthcare providers Investigate and report confirmed cases Ensure clinicians screen potential cases appropriately and have latest case definitions Laboratory Testing and Support Services Facilitate appropriate laboratory testing and interpretation of results Vector Control and Surveillance For regions with Zika-carrying mosquitos (not us!) Develop a plan Identify and train partners Educate communities

FPHS Connection Additional Important Services FOUNDATIONAL PUBLIC HEALTH SERVICES Foundational Programs Foundational Capabilities Communicable Disease Control Chronic Disease & Injury Prevention Environmental Public Health Maternal Child Family Health Access to Clinical Care Vital Records Across all Programs Assessment (surveillance and epidemiology) Emergency preparedness and response (all hazards) Communications Policy development and support Community partnership development Business competencies

Zika Response Guidelines (Adapted from CDC) Maternal and Child Health Surveillance and Response Rapid Birth Defects Monitoring and Follow-Up Engage with state-level and national pregnancy registry Reach healthcare providers to counsel patients about reducing risk of sexual transmission and reducing mosquito exposure Ensure obstetric providers increase screening and adhere to CDC monitoring guidelines Educate healthcare providers about birth defect reporting procedures Provide training for providers to evaluate infants for congenital Zika virus infection Assess and plan for needs of families with a child with microcephaly or other major birth defect

Zika Response Guidelines (Adapted from CDC) Zika Prevention: Traveler Health Educate travelers and clinicians about risks related to specific destinations Provide prevention recommendations Clinician Outreach and Communication Review updates to Zika material Supplement as needed with local materials Share information with healthcare providers Risk Communication and Community Education Develop coordinated messaging with key partners

Polling Question If we were to have an outbreak of an emerging disease such as Zika or the next unknown pathogen, what are the greatest vulnerabilities in your practice setting? A) Surveillance and epidemiology B) Support for and coordination with healthcare providers/systems C) Emergency response (incident management) capability D) Communications capacity E) Other [type in chat box]

Questions?

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