The virus known as Zika continues to affect 42+ countries and territories that have confirmed local, vector-borne transmission of the virus. Areas include Africa, Southeast Asia, Latin America, the Pacific Islands, the Caribbean, and the United States.
On Monday, August 1, 2016 the Centers for Disease Control and Prevention (CDC) issued its first travel warning for a location within the boundaries of the United States. A total of 14 people were infected with Zika in the Miami, Florida region causing the CDC to warn travelers of the potential risk. While this was the first time the CDC has issued a travel warning in the United States, there have been many surrounding international locations affected by Zika. One area that has seen such effects is the Caribbean, which has been combating Zika since 2015.
The travel notices issued by the CDC range from Watch Level 1: Practice Usual Precautions to Alert, Level 2: Practice Enhanced Precautions, and Warning Level 3: Avoid Nonessential Travel. Currently, the Caribbean countries under watch have been listed at a Level 2. One area of major concern is St. Eustatius, which has been the most recent to be issued a travel notice from the CDC on July 15, 2016.
The Zika virus has put a lot of additional pressure on tourism. The World Travel & Tourism Council has determined that tourism accounts for 30% of Jamaica’s economy, for example. They also reported that in 2014, 26.3 million tourists and 24.5 million cruise ship passengers had visited the Caribbean and spent $29.2 billion. More than half of those visitors were from the United States.
The Caribbean Public Health Agency acknowledges this threat to the infrastructure of the Caribbean and looks to protect the region’s $29 billion industry.
Dr. C. James Hospedales, the executive director of the Caribbean Public Health Agency, stated at a news conference for the Caribbean Public Health Authority’s (CARPHA) launch of its Mosquito Awareness Week in Trinidad and Tobago that, “We can never let our guard down where infectious diseases are concerned, and that is particularly so in our tourism-dependent Caribbean region.”
New research continues to prove that Zika has been linked to severe health outcomes for women who are or could become pregnant. According to the CDC, a woman diagnosed with the Zika virus can pass it on to her fetus during pregnancy or at delivery. This has caused an increased fear among pregnant women, as reports from Brazil have shown that with the outbreak of Zika, there has been an increase of babies born with microcephaly, a condition causing severe brain and eye defects, hearing loss, and impaired growth. The CDC has confirmed this correlation.
After confirming the link between microcephaly and Zika, Director Thomas Frieden, a scientist at the CDC stated: “The CDC is launching more studies to determine whether children with that rare condition represent the tip of the iceberg of what we could see in damaging effects on the brain and other developmental problems.”
On February 26, 2016, the Secretary of Health and Human Services, Sylvia Burwell, determined that “there is a significant potential for a public health emergency that has a significant potential to affect national security or the health and security of United States citizens living abroad and that involves Zika virus.” Similar emergency acts reported by the U.S. Food and Drug Administration were used to address the Ebola virus outbreak in 2014. Due to the determination by Burwell that Zika is a high threat to the United States, pharmaceutical and health executives set in motion to create different ways to detect Zika by diagnostic procedures.
Previously, the WHO also declared a Public Health Emergency of International Concern on February 1, 2016, about which the Emergency Committee stated: “In their view, a coordinated international response is needed to minimize the threat in affected countries and reduce the risk of further international spread.”
Other aedes aegypti transmitted diseases
This is not the first time the Caribbean has dealt with an epidemic caused by a mosquito-transmitted virus. The Chikungunya virus (or CHIK-V), dengue, and yellow fever all thrive in warm climates. All four viruses are vector diseases that can be passed on to humans by the Aedes aegypti mosquito.
Aedes aegypti is most often seen in the Caribbean due to the hot and humid environment; this mosquito species is cold blooded and prefers a temperature above 80 degrees. A. aegypti thrive on coconut husks, cocoa pods, bamboo stumps, tree holes, and rock pools in order to lay their eggs ideally with available resources such as water around them. Colder climates may see the disease present among the Aedes albopictus species of mosquitos which can adapt to survive in cooler climates with a wider range of water-filled breeding sites.
In 2014, the CHIK-V virus invaded the Caribbean, and more than 73,000 cases over 25 destinations were reported by the CDC. “Chik”, which is derived from the Kimakonde language means ‘to become contorted’, results in joint pain and swelling, rash, headache, muscle pain, nausea, fever, and fatigue. The virus is rarely fatal, and symptoms usually last for 2-3 days, remaining in the human system for 5-7 total days; however, symptoms may last months to years after they acquire CHIK-V causing aches and joint pains for a very long time . It can sometimes result in neurologic diseases such as Guillain-Barre syndrome, meningoencephalitis, and cranial nerve palsies. There is no cure for the disease, so treatment focuses on relieving some symptoms.
The Pan American Health Organization (PAHO) reported on March 18, 2016 that there were only 31,000 cases in 2015 representing a 5-fold decrease from the previous year. CHIK-V can sometimes be mistaken for another disease passed on by mosquitos called Dengue if not properly diagnosed.
Dengue is one of the fastest growing vector-borne diseases that caused an increased number of cases in the Caribbean in 1995. The WHO reported that the Caribbean experienced the worst dengue epidemic, lasting 15 years with 200,000 cases. Internationally, dengue has had 400 million cases of infections in 125 million countries. The symptoms of dengue include a flu-like illness with vomiting, skin rash, and mild bleeding. Another rare, but potentially fatal case called the dengue hemorrhagic fever (DHF) can develop if unrecognized.
Integrated Vector Management
Both chikungunya and dengue have been previously combated by the Integrated Vector Management (IVM) approach, which was reported by the WHO as a “rational decision-making process for the optimal use of resources for vector control.” This approach includes five key elements: 1) advocacy, social mobilization, and legislation, 2) collaboration within the health sector and with other sectors, 3) integrated approach, 4) evidence-based decision-making, and 5) capacity-building.
No vaccines are currently available for chikungunya. However, earlier this year the first dengue vaccine, Dengvaxia (CYD-TDV) by Sanofi Pasteur, has been registered in several countries according to the WHO. Additional vaccinations are still under development for combating dengue.
Despite having a vaccination developed for it, yellow fever is still responsible for 30,000 deaths every year. It is known as yellow fever because some patients’ infections cause them to develop jaundice; which is a medical condition where the skin becomes yellow due to complications, such as obstructing the bile duct, with the liver. Other symptoms include fever, headache, muscle pain, nausea, vomiting, and fatigue. According to the WHO, approximately half of the patients who develop more of the severe symptoms of yellow fever will succumb to it within seven to ten days. In the Caribbean, it is required that all travelers have their yellow fever vaccine before entering the country.
Previous experience has shown that a vaccine is the most effective way to contain the spread of a mosquito-borne disease. Program initiatives have also been shown to be successful in reducing the number of cases in high-risk environments. However, the war against Zika is one that can pose a new threat to prevention efforts.
Zika can be transmitted sexually by people of any gender according to the CDC. The first sexually-transmitted case that was reported occurred in New York City by a man who recently traveled to a Zika-affected region outside the United States. Upon returning he had condomless sex with his partner, who then was diagnosed with Zika. This sort of transmission makes prevention of Zika even more daunting and complex.
So what is the delay in creating a worldwide plan of action to prevent and eliminate Zika? Why are we not running full force against this virus with everything we have?
The WHO and PAHO have generated a Zika Strategic Response Plan, “which outlines four main objectives to support national governments and communities in prevention and managing the complications of Zika virus and mitigating the socioeconomic consequences: detection, prevention, care & support, and research.” The plan specifically highlights the following:
- the potential for further international spread of Zika virus given the wide distribution of Aedes mosquitoes that are capable of transmitting Zika virus,
- the lack of population immunity in areas where Zika virus is circulating for the first time and which allows the disease to spread quickly,
- the absence of vaccines, specific treatments, and rapid diagnostic tests, and
- inequalities in access to sanitation, information, and health services in affected areas.
However, in order to implement the Zika Strategic Response Plan from July 2016 to December 2017, the organizations will need $122.1 million. On February 22, 2016, a $1.9 billion request for emergency funding was sent to the United States Congress by the White House to respond to Zika both domestically and internationally. To this date, there is still no approval on a spending bill.
The WHO only has $7.9 million to fight Zika in 61 countries, which is not enough. In the Zika Strategic Response Plan, the WHO is quoted saying, “activities proposed by WHO and its partners have been underfunded to date, and without sufficient funding, the response is likely not to succeed.”
At Georgetown Law, Lawrence Gostin, a professor of global health law, was reported saying: “If you look at its [the WHO] record in response to diseases, whether it’s Yellow Fever, Ebola, now Zika, you’ll find that they constantly underestimate the amount that it will cost, and then are unable to mobilize the funding for the small amounts that they even said they need.”
Additional options such as the UN Zika Response Multi-Partner Trust Fund that was announced on May 6, 2016 also has no funding yet.
Without the funding to combat Zika in areas where the virus is at the highest risk for infection, people will continue to see long-term health and economic issues. This will continue to have a lasting impression on the Caribbean as they face economic challenges due to the fear of Zika detracting tourism. With a lower number of travelers comes hardship for those that rely on tourism to support their family. Additionally, tourism may cause Zika to continue to spread internationally as people visit areas where the virus is present.