Public Health Advisory: The Emerging Mosquito-Borne Zika Virus OutBreak

Rachel Bevins Morgan RN, BSN 9/16/2016

Overview

Emerging infectious diseases constitute a clear and persistent threat to the health and well-being of people and animals around the world. Prior to the 1940s the Zika virus was known only to occur in Africa and Southeast Asia, but from Jan. 1, 2007 to April 6, 2016, Zika transmissions have been documented in a total of 62 countries and territories. Since Feb. 1, 2016, the World Health Organization (WHO) has recognized the outbreaks as a Public Health Emergency of International Concern (PHEIC) and recommended enhanced surveillance of cases of microcephaly and Guillain-Barre’ Syndrome (GBS) which coincided with the Zika outbreaks. 

WHO released a plan Feb.17 to guide the international response to the spread of Zika, which may be linked to birth defects such as microcephaly. Until more is known, the Centers for Disease Control (CDC) and Prevention strongly advises pregnant women to consider postponing travel to Zika-affected areas, or talk to their health care provider and strictly follow steps to avoid mosquito bites during the trip.

HHS Declares a Public Health Emergency in Puerto Rico

August 12, 2016–At the request of Governor Alejandro Garcia Padilla, Health and Human Services (HHS) Secretary Sylvia Burwell declared a public health emergency for Puerto Rico, signaling that the current spread of Zika virus poses a significant threat to public health in the Commonwealth relating to pregnant women and children born to pregnant women with Zika. The declaration allows HHS to provide additional support to the Puerto Rican government and through it the government can:

  • Apply for funding to hire and train unemployed workers to assist in vector control and outreach and education efforts through the U.S. Department of Labor’s National Dislocated Worker Grant program; and 
  • Request the temporary reassignment of local public health department or agency personnel who are funded through Public Health Service Act programs in Puerto Rico to assist in the Zika response.

According to the Puerto Rican Department of Health, as of August 12 there were 10, 690 laboratory confirmed cases of Zika in Puerto Rico, including 1,035 pregnant women. 

First Cases of Locally Acquired Zika Infection Diagnosed on Mainland U.S.

July 29, 2016–In the midst of summer, the first cases of locally acquired Zika infection have been reported in the continental United States in Miami-Dade and Broward counties Florida. In a press release today, the Florida Department of Health stated that they had gathered enough information as part of its ongoing investigation into non-travel related cases of Zika in these counties to conclude that a high likelihood exists that four cases are the result of local transmission. At this time, the department believes that active transmission of the Zika virus are occurring in one small area in Miami-Dade County, just north of downtown. These local cases were identified by clinicians who brought them to the attention of the department and have not yet been reflected in the CDC reported cases.

The Food and Drug Administration (FDA) has requested that all blood establishments in the Miami-Dade County and Broward County cease collecting blood immediately until they implement testing of each individual unit of blood collected in the two counties with an available investigational donor screening test for Zika virus RNA or until they implement the use of an approved or investigational pathogen inactivation technology. The FDA has recommended that the surrounding counties implement the same precautions to help maintain safety of the blood supply as soon as possible.

U.S. Senator Marco Rubio (R-FL) issued the following statement expressing his concern and urging the Obama Administration to use all the tools at their disposal to reprogram existing public health emergency funding in the short term to deal with Zika. On February 22, 2016, the Obama Administration had requested more than $1.89 billion in supplemental funding to respond to the Zika outbreak. The House and Senate passed separate funding measures in May, but congress failed to come to a final agreement before going into a seven-week summer recess. In the absence of new funding, the Obama administration has worked to identify funding that can be reprogramed for the purpose of fighting Zika.   

Advice for people living in or traveling to Wynwood, a neighborhood in Miami, FL 

New Funding and Interim Guidance

On July 21, 2016, the CDC announced they were awarding $60 million to states, cities, and territories to support public health efforts to protect Americans against Zika. The funding will support activities including epidemiological surveillance and investigation, improving mosquito control and monitoring, and strengthening laboratory capacity. It will also support participation in the U.S. Zika Pregnancy Registry to monitor pregnant women with Zika and their infants, as well as Zika-related activities in U.S.-Mexico border states.

The CDC also issued updated guidance and information for healthcare providers caring for pregnant women with possible exposure, and updates for the prevention of sexual transmission. Because diagnosis can be complicated the guidance expands the timeframe, up to 14 days, that testing for the viral particles in the blood of pregnant women can be offered. New information has indicated that some infected pregnant women can have evidence of Zika virus in their blood for longer than the previously recommended seven-day window for testing. 

According to the CDC as of September 14, 2016

  • Zika virus disease and Zika virus congenital infection are nationally notifiable conditions.

  • This update from the CDC Arboviral Disease Branch includes provisional data reported to ArboNET for January 1, 2015 – September 14, 2016.

U.S. States

  • Travel-associated Zika virus disease cases reported: 3,132
  • Locally acquired vector-borne cases reported: 43
  • Laboratory acquired cases reported:1
  • Total: 3,176
    • Sexually transmitted: 26
    • Guillain-Barre' syndrome: 8
  • ​Pregnant women with any laboratory evidence of possible Zika virus infection: 731*
    *This update includes aggregated data reported to the US Zika Pregnancy Registry as of Sept. 8, 2016.

U.S. Territories

  • Travel-associated cases reported: 65
  • Locally acquired cases reported: 17,629
  • Total: 17,694
    •  Guillain-Barré syndrome: 34
  • Pregnant women with any laboratory evidence of possible Zika virus infection: 1,156*
    *This update includes data from the US territories reported to the US Zika Pregnancy Registry and data from Puerto Rico reported to the Zika Active Pregnancy Surveillance System as of Sept. 8, 2016.

Zika Travel NoticesTravel notices currently exist for Cape Verde, the Caribbean, Central America, Mexico, Samoa, and South America. 2016 Zika Outbreak Map

Frequently Asked Questions

  • What is the Zika Virus: Zika virus is an emerging mosquito-borne virus predominantly found in tropical areas with large mosquito populations.
  • How is the Zika virus transmitted?
  1. The virus is primarily transmitted to people through the bite of an infected Aedes species mosquito, which are the same mosquitos that spread the dengue and Chihungunya viruses.
  2. In rare cases, a mother infected near the time of birth can infect a newborn, or a fetus during pregnancy.
  3. Spread of the virus through blood transfusion (American Red Cross statement on blood transfusions) and sexual contact (Sexually transmitted case confirmed in Texas by CDC) have been reported according to the CDC.
  4. Sexual TransmissionUpdate: Interim Guidelines for Prevention of Sexual Transmission of Zika Virus — United States, Feb. 23, 2016
  • What is the incubation period before the onset of symptoms?: The incubation period of the virus is not clear, but is likely only a few days.
  • What are the most common symptoms related to the Zika virus?: About 1-in-5 people infected with Zika virus become ill. The most common symptoms are similar to other arbovirus infections such as dengue, and include fever, skin, rashes, conjunctivitis, muscle and joint pain, malaise, and headache. These symptoms are usually mild and last for two to seven days.
  • How is the Zika virus diagnosed?: A Zika diagnosis should be confirmed with a blood test.
  • What should I do if I have Zika?
  1. During the first week of infection, Zika can be found in the blood and passed from an infected person to another person through mosquito bites. These mosquitos can then spread the virus to others, so avoid mosquitos during the first week.
  2. See a health provider immediately if you’re pregnant and develop a fever, rash, joint pain, or red eyes within two weeks after traveling to a country where Zika virus cases have been reported. Be sure to give the health provider an accurate history of your travels and symptoms.
  • What is the treatment for a typical case of the Zika virus?
  1. Get plenty of rest.
  2. Drink fluids to prevent dehydration.
  3. Take medicine such as acetaminophen to reduce fever and pain.
  4. Do not take aspirin or other non-steroidal anti-inflammatory drugs.
  • Why are there specific recommendations for pregnant women?

There may be a link between a serious birth defect called microcephaly—a birth defect where a baby’s head is smaller than expected when compared to babies of the same sex and age—and other poor pregnancy outcomes and a Zika infection in a mother during pregnancy. Babies with microcephaly often have smaller brains that might not have developed properly.

The CDC recommends that pregnant women take special precautions by postponing travel to any area where the Zika virus is active, talk with your doctor first, and follow the steps to prevent mosquito bites during your trip. If you are trying to become pregnant talk with your doctor about your plans before you travel and the risks posed from infection.

  • Is there a vaccine to prevent or medicine to treat Zika?: No. There is no vaccine to prevent infection or medicine to treat Zika.
  • Once infected, is an individual immune for the remainder of their life?

Although little is known about the virus, the prevailing school of thought is that once infected individuals are protected from future episodes of illness from the virus

Federal Preparations and Funding

Zika Response Funding

June 23, 2016 Update–In Feb. of 2016, the Obama Administration made a formal request for $1.9 billion in emergency supplemental funding to address the public health threat posed by the Zika virus. As congress deliberated on the request for supplemental funding, the Obama Administration identified $589 million in existing funds that could be immediately redirected toward public health activities focusing on the virus. 

Status of Congressional Actions

Since the president’s request for emergency supplemental funding in Feb., the House passed a standalone bill that would provide only $622 million in funding, fully offset, to last through the end of the current fiscal year (FY). The Senate passed $1.1 billion in emergency funding–meant to last through FY 2017–as an amendment to a military construction appropriations bill. Neither bill would provide an amount close to the $1.9 billion the Administration is seeking.

In the early hours of June 23rd, the House approved the Military Construction and Veterans Affairs and Zika Response Appropriations Act final Conference Report (House Report 114-640). The conference report included $1.1 billion for domestic and international efforts to fight the Zika virus. Approximately $750 million of these funds are offset.  

The conference report was passed 239-171 on mostly party lines at about 3:12 a.m. The conference measure must still be considered by the Senate, and it is not clear if it will be signed into law by President Obama, who had requested $1.9 billion for the Zika efforts. According to the Conference Report summary, the $1.1 billion includes:

  • $476 million for the Centers for Disease Control and Prevention (CDC) to fund readiness in states and territories with heavy mosquito populations, enhance laboratory activities, continue disease surveillance, international response, and to fund emergency preparedness grants to state local and territorial health departments that may have experienced reductions due to redirection of funding to fight Zika.
  • $230 million for the National Institutes of Health (NIH) to support vaccine research and the rapid advanced development and commercialization of new vaccines and diagnostic tests for Zika virus.
  • $85 million for the Biomedical Advanced Research and Development Authority (BARDA) for fiscal year (FY) 2016 for research and development activities related to Zika, including the deployment of new rapid diagnostic tests.
  • $40 million for community health centers, $6 million for the National Health Service Corps, and $95 million via the Social Services Block Grant to be used in U.S. territories and other areas that are experiencing the highest rates of Zika transmission.
  • $175 million for programs through the State Department and the United States Agency for International Development (USAID) in FY 2016.
  • $145 million for Global Health programs to target international mosquito control efforts, and funding for the Zika-related activities of the World Health Organization (WHO), the Pan American Health Organization (PAHO), the UN Children’s Fund (UNICEF), and the Food and Agriculture Organization (FAO) to fight the disease before it spreads further into the U.S.

The Conference Report also contains funding for military construction and veterans benefits programs at $82.5 billion, an increase of $2.6 billion above current levels. The chamber gaveled out at 4 a.m. which began the July Fourth recess. The next votes in the House are expected at 6:30 p.m. July 5.

Additional materials including a summary of the report is available online on the House Appropriations Committee Web page

CDC Awards Funds for States and Territories to Prepare for Zika

July 1, 2016—The CDC announced they were awarding $25 million in funding to states, cities, and territories to support their efforts to protect their communities from the Zika virus infection and associated adverse health outcomes. These funds have been awarded to health departments in areas most at risk for outbreaks of Zika and may be used through June 2017. Selection of funding recipients was based on the risk of local transmission as determined by the estimated range of the Aedes mosquito species known to transmit Zika virus in the U.S., history of mosquito-borne disease outbreaks, and size of population.

The funds may be used to rapidly identify and investigate a possible outbreak in their communities, to coordinate a comprehensive response across all levels of government and non-governmental partners (including the healthcare sector), and identify and connect families affected by Zika to community services. Funding can also be used to purchase preparedness resources like repellent, screens, and supplies for Zika Prevention Kits.

The Zika virus is usually mild with common symptoms of fever, rash, joint pain, and conjunctivitis (red eyes) which lasts for a few days. However, if the infection occurs in a pregnant women in can cause microcephaly and other severe fetal brain defects. It has also been linked to Guillain-Barre’ syndrome, an illness affecting the nervous system causing muscle weakness and sometimes paralysis. 

The Food and Drug Administration (FDA)

On Feb. 17. the FDA issued recommendations for blood donor screening and deferral to reduce the risk of transmitting Zika virus through transfusions. In areas without active Zika virus transmission, FDA recommends deferring from blood donation people who have had Zika-like symptoms in the past four weeks; sexual contact with someone who has traveled to or lived in an area with active Zika virus transmission in the past three months; or traveled to areas with active transmission in the past four weeks.

Medicaid Benefits Available for the Prevention, Detection and Response to the Zika Virus

The Centers for Medicaid and CHIP Services (CMCS) released and informational bulletin June 1, 2016, to inform Medicaid agencies and interested stakeholders about how Medicaid services and authorities can help states and territories prevent detect, and respond to the Zika virus.

Although the Zika virus had historically been in Sub-Saharan Africa, over the last seven year its moved into the South Pacific, and many parts of the Western Hemisphere. It is primarily spread through the bite of the Aedes species mosquito, but can be sexually transmitted from man to a partner regardless of the partner’s gender. After sexual transmission, the virus can be passed on from a pregnant women to her fetus, and infection during pregnancy has been linked to serious birth defects of the brain called microcephaly, which involves incomplete brain development and other severe brain defects. Zika has also been linked to Guillain-Barre’ syndrome (GBS), a rare disorder that can cause muscle weakness and paralysis for a few weeks to several months. The condition is treatable and most individuals recover from GBS, but some have permanent damage.

The CDC is continuing to review medical information related to the virus and has issued guidance and information to prevent transmission. This CMCS bulletin highlights services that will be particularly important to address Zika virus and associated health conditions. In each instance, CMCS has identified authorities and flexibilities states and territories have to provide these critical services to beneficiaries in their programs.

Prevention

There is no vaccine available for the Zika virus. The major means of prevention available are mosquito control, protection against mosquito bites, and contraception for women of childbearing age who do not wish to become pregnant.

  • Repellents–State Medicaid programs may choose to cover mosquito repellents when prescribed by an authorized health professional and these products would be eligible for Federal Financial Participation (FFP) under such circumstances.
  • Family Planning and Services for Men and Women Who Are of Child Bearing Age or Women Who Are Pregnant:
    • Family planning counseling. States may offer family planning counseling to help beneficiaries make informed and responsible decisions about family planning and reproductive health, as well as learn safe sexual practices to reduce Zika transmission.
    • Contraception. The family planning services and supplies benefit covers services that may prevent the transmission of the Zika virus by providing access to barrier method contraceptives such as condoms and other methods of contraception that prevent or delay pregnancy. States may also cover items such as oral contraceptives, condoms, diaphragms, foams, gels, patches, rings, injections, tablets, emergency contraceptives, and long-acting reversible contraception (LARC). LARC includes both intrauterine devices (IUDs) and contraceptive implants.

Services provided under the family planning benefit are eligible for enhanced FFP at 90 percent.

Detecting Zika Infection and Associated Health Risks

The Medicaid program offers a wide array of services that states can cover to assist with diagnosing the Zika virus.

Diagnostic services are instrumental in detecting a Zika virus infection as well as associated health risks, such as microcephaly. They include services such as CAT scans, MRIs, ultrasounds, blood tests, urine tests, and genetic testing. If a pregnant women tests positive for Zika, a physician may use other tests such as an ultrasound to assess the condition of the fetus. Other tests may follow as appropriate to assess abnormalities once detected.

States can make these services available to adults through the optional diagnostic services benefit, screening services benefit, other preventive services benefit, and other laboratory and x-ray services benefit.

States are required to cover all medically necessary diagnostic services related to the detection of a Zika virus infection, including diagnosis of microcephaly and other birth defects without limit to individuals under the age of 21 through the Early Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.

Treatment

Treatment of individuals with the Zika virus or those with conditions that may be a result of the Zika virus is supported by services available through the Medicaid program.

A comprehensive range of services for beneficiaries under the age of 21, including services related to the treatment of the Zika virus and microcephaly or other Zika-related disabilities, is covered without limit under the mandatory EPSDT benefit. The EPSDT benefit provides coverage of all medically necessary treatment services described in section 1905(a) of the Social Security Act for beneficiaries under the age of 21, even if the services are not covered for adults.

  • Targeted Case Management (TCM) Services–TCM services is an optional benefit that can be used by states to assist Medicaid beneficiaries in coordinating access to needed medical, social, educational and other services. TCM includes assessment, development of a care plan, referral and monitoring. Children with Zika related disabilities may require developmental therapies, supportive services, and symptom management.
  • Physical Therapy and Related Services–Individuals recovering from Zika related disabilities, especially GBS, may need physical therapy and related services. States have an option to provide speech, physical, occupational, and audio logic therapy to beneficiaries.
  • Prescribed Drugs–states should ensure that their Medicaid coverage is sufficient to provide for management of symptoms related to Zika infections. Specifically, individuals with Zika may be prescribed antipyretic analgesics, like acetaminophen (brand name Tylenol), to relieve fever and pain, as well as electrolyte solutions to prevent dehydration.
  • Long-term Services and Supports–individuals and infants affected by Zika may require long-term rehabilitative care in a nursing facility or the home setting. States have significant flexibility in designing these services.

Additional Benefit Options and Relevant Authorities

  • Additional services provided by managed care plans. At their discretion, managed care plans may choose to provide products and/or services beyond what is included in the benefit package under their contracts, provided that such additional services are not included in the capitation rates. For example non-medical measures to deter mosquitos such as inspections to determine likely mosquito breeding locations, aerosol insecticides (dispensed to the air or environmental surfaces), protective clothing, window screens, and other environmental modifications to combat the spread of the Zika virus. These costs may not be considered in development of the capitation rates by the state, nor may the state mandate their provision.
  • Extended Medicaid Services for Pregnant Women. Because of health concerns associated with the Zika virus, the state could determine that all pregnant women may receive more than one ultrasound when medically appropriate or necessary. The CDC recommends serial ultrasounds should be considered to monitor fetal anatomy and growth every 3-4 weeks as well as referrals to a maternal-fetal medicine or infectious disease specialist with expertise in pregnancy management.
  • Waivers and Demonstrations. There may be additional opportunities to cover products and/or services related to the prevention, detection, and treatment of Zika through a section 1115 demonstration or through a sectin 1915(b)(3) waiver.

Additional Resources

  1. Zika Virus Risk-Based Preparedness and Response Guidance for States
  2. Zika Communication Planning Guide for States
  3. Interim CDC Recommendations for Zika Vector Control in the Continental United States
  4. The Top 10 Zika Response Planning Tips for States, Local, Tribal, and Territorial Health Officials 
  5. Resources and Publications for Public Health Partners