>> well, good morning, and welcome to the nextsession of the zap. i'm anne schuchat, thedeputy director for cdc, and want to join inwelcoming all of you to this really important day. you know, in this session,the rubber hits the road, or the mosquito hitsthe windshield. to paraphrase a famouspolitician, "all mosquito control is local."
and in this session, we're goingto hear from a state, city, county, and a very crucialterritory or jurisdiction that are coping with zika virus and making plansaround zika control. i think we will have timefor questions at the end. and what i really want to dois introduce all four speakers and then get right to it. so, thanks for returning. and for those on the side, we dohave some seats down in front.
the four speakersare carina blackmore, who's the acting director ofthe division of disease control and health protectionin florida. daniel kass, who's thedeputy commissioner for environmentalhealth in new york city. umair shah, who's theexecutive director of the local health authorityin harris county, texas. and brenda rivera-garcia, who'sthe territorial epidemiologist for puerto rico'sdepartment of health.
and with that, carinawill begin the session. >> all right. thank you so much forinviting me to speak. i will be talkingabout the coordination of mosquito-borne diseasesurveillance and response in florida for a few minutes. and to put this presentationinto context, florida has had along experience with mosquito-borne diseases.
in fact, the florida stateboard of health was created as a result of ayellow fever epidemic in jacksonville in 1889. and at the time,we also had malaria and dengue commonlycirculating in the state. mosquitoes also had a majorimpact on population growth in the state, and not until wehad mosquito control districts we really saw a majorgrowth in population on the florida peninsula.
the first mosquito controldistrict was formed in 1925. and as was previously mentioned,these are districts either under the auspices ofcounty organizations or independent taxing districts. because of the importanceof mosquito-borne diseases in florida, we have astrong infrastructure of mosquito-borne diseaseresearch in the state both at universities and the statepublic health laboratories as well.
so, the diseases thatwe worry about mostly in florida currently arest. louis encephalitis, eastern equine encephalitis,and west nile virus disease. but even though we havebetter mosquito control and better housing, thevectors aedes aegypti and anopheles quadrimaculatus,vectors for dengue and malaria, are still present in the state. so, periodically, wesee transformation of these non-endemicmosquito-borne diseases.
and lately, we've alsoseen local transmission of chikungunya fever. mosquito-borne diseasecontrol is very complex. i think we have gottenthat message, and we certainlyrecognize that in florida. and as a result, we've had aninteragency arbovirus task force in place for almost 20 years. this task force includes membersof the department of health, the department of agricultureand consumer services,
which is the agency that overseemosquito control in florida, the department ofenvironmental protection, fish and wildlife experts, florida mosquitocontrol association, florida environmental healthassociation, the association of county healthofficers in florida, usda, and several universitieswhich have interests in mosquito-borne diseaseresearch or diagnostic research. the major output of this groupis a guidance document called
"surveillance and control of selected mosquito-bornediseases in florida". it provides guidance onpublic health surveillance, and also includes amosquito-borne disease response plan that is based on dataon mosquito testing results, animal testing results, andhuman case surveillance data. and as a result of those datapoints, we declare advisories, alerts, and emergencies. we have an associatedcommunication plan
that includes routinepress releases and other marketing materials,traditional marketing materials, door hangers, pamphlets,et cetera, and certainly also anoutreach through social media. and that's based on ourstandardized messaging around drain and cover. what really helps ourcoordination and standardization of mosquito-bornedisease response in florida is this stronginfrastructure that we have
in mosquito controlin the state. the department of agriculture and consumer services has astatutorily-mandated advisory council called the floridacoordinating council on mosquito control that advisesthe department of agriculture on best practicesaround mosquito control, and also the best use ofpesticides for mosquito control. and many of the same partneragencies and groups involved in our arbovirus task forceis involved in this council,
which provides agood opportunity for further coordinationand collaboration. we do also have very coordinatedtraining of the various partners in this effort in thestate through agencies. but florida mosquito controlassociation has a great role and wonderful trainingprograms that we participate in. and the university of florida, the florida medicalentomology laboratory, which is a premierresearch institution,
also has an extensionfunction that provides training in medical entomology. we have joint exercises toexercise response to animal and human diseases ofmosquito-borne origin. but because of our location, we do see hurricanesand flooding as well. and these tend to produce majormosquito outbreaks that need to be dealt with, andwe exercise those also. so, what is then the impact ofthe state-level coordination
to support local efforts in mosquito surveillanceand control? it is a routine, standardized,science-based response that we have in florida thatincludes mosquito surveillance and control in response to humanand animal cases of disease. for zika, for example, whenthe public health laboratory is still the only sourceof testing, when we hear about cases or suspect casesthat we want to test it at the public healthlaboratory, immediately,
mosquito control is notified. and they go out and assessmosquito levels and needs for control around the homesor other areas of exposure. we do further coordinatedactive case surveillance around outbreaks when wehave aedes aegypti involved and particularlybecause, as was mentioned, this is a very difficultmosquito to control. it needs involvementfrom the community, from the property owner, andmany times a door-to-door effort
that often then is joinedbetween health departments and mosquito controldistricts in florida. and we share then themessaging to the public and the press aroundthese efforts. we also benefit from being ableto do real-time adjustments in response to activitiesin the state. this involves conferencecalls, using the data at hand to really assess whether theappropriate mosquito response is in place or whetheradjustments need to be made.
this is particularlyimportant when we have new and emerging issues in florida. so, for example, after the2009, 2010 dengue outbreak in key west, we had a newawareness among healthcare practitioners towards dengue. and suddenly, we actuallydetected local transmission of dengue each yearin the state. and although we have a fantasticmosquito control program, probably one of the bestin the country in the keys,
one that is very experienceddealing with aedes aegypti, we recognized that that's notnecessarily true in other parts of florida because aedes aegyptiis not the typical nuisance mosquito that we worry aboutmost of the time, the mosquito that people calland complain about. so, many of the districts werenot necessarily doing a routine surveillance for this mosquito. we have built a lot of capacitysince then, both expertise and trapping resources, andare a lot better prepared today
than we were then. we also had a malariaoutbreak in florida in 2003. and at the time,we were then able to get technicalexperts together to advise the mosquitocontrol districts because anophelesquadrimaculatus, while present in florida, it is not amajor nuisance mosquito and it does not really get into the nuisance mosquitotrapping systems that we have.
so, a different responsewas needed. surveillance effortsneeded to be modified. and our technical expertscould help us with that so we could control thatoutbreak at the time. with that, thank you somuch for your attention. i will turn over to dan kass. [ applause ] >> so, thank youall for having me. and thanks again to allof the people responsible
for organizing thisimportant conference. i wanted to talk to you alittle bit about our program in new york city and howit's going to be modified. as most of you know,we were the epicenter for the initial discovery oftransmission of west nile virus in the continental unitedstates about 15 years ago. so, i'm going to start bytalking about the elements of our existing mosquitocontrol program, how we expect to modify it, and what someof the considerations are
for that modification. like most mosquitocontrol programs, ours is really grounded in an integrated pestmanagement approach. and i will be talking about eachof these essential elements. but our response involvesa tremendous amount of community engagement,extensive employment of use of larvicide both in aerialnon-populated areas as well as ground-based forpopulated areas.
and we carry out truck-basedadulticiding in areas of the city wherecriteria are met based on disease-based specials. so, just to quickly runthrough a handful of slides so you can get asense of the reach of our current west nilevirus control program, we do extensive communityoutreach targeting neighborhoods and populations at elevatedrisk of west nile virus, nursing homes,
naturally-occurringretirement communities, other vulnerable populations. includes direct outreach,distribution of educational materials,spray notifications, and some repellant distribution. our surveillance program isreally built around trying to detect culex mosquitoes. we have 61 permanent trapsites deployed strategically across the city withthe locations optimized
for their detectionbased on both habitat and historical patterns of thespread of these mosquitoes. when a mosquito pooltests positive, we deploy supplemental traps in a geographic areasurrounding the positive pool to determine the geographicreach and the extent of the population itself. we have a 3-1-1 service to report standingwater complaints,
and we do proactive inspections in a variety of settingsas well. last year, we had about 1,700complaints that resulted in about 1,500 inspections. we have the authority under somemodifications to our health code and commissionerrules to issue notices of violation upon firstinspection and to treat where we're successfullyable to gain access. we do extensive groundlarva sighting based
on our 15-year-oldsurveillance effort. we do routine treatment atmore than 800 locations, including cemeteries,parks, ponds, and areas with naturaldepressions. over the course of the mosquitoseason, we apply larvicide at nearly 5,000 other sites. and our larvicide has,until now, involved the use of bacteria-based vectobac,vectolex, and vectomax. this is a map of the catchbasins in new york city,
each of which is treated at least twice eachmosquito season. these are important breedingsites for culex mosquitoes. and this is one of the few areaswe rely on contracting work in new york city to conduct. this map is a nice summaryof what happened in 2015 just so you can get a sense ofthe scale of activity upon which we intend tobuild a modification for addressing aedes mosquitoes.
the shaded areas are areas wherewe adulticided at least once. the red dots are areas wherewe had positive mosquito pools. the stars are wherewe had human cases. we know that last year we hadabout 31 adulticiding events which covered about a thirdof the geographic area of new york city wherethey were home to more than 800 infectedmosquito pools. it was a very rough yearfor us both in terms of west nile virus burdenas well as programmatic.
i included an image hereat dr. frieden's request of the helicopter that thehealth department uses back when we first beganthis program. my predecessor onthe job happened to be a helicopter pilotand made a convincing case for requiring a helicopter,which was really fortuitous. because if it happenedunder my watch, we would be operatingeither from the back of a bicycle or amazda hatchback.
[ laughter ] so, what we learned -- welearned a variety of things over the course of thewest nile virus response. it's really helping toinform the work that we do. and i want to just coverthese in some detail because they're important. the first, the publicharley monolithic in a diverse city like newyork city did strongly object to aerial adulticiding in theearly year of the first year
of our west nilevirus control program. now, granted, wewere using malathion. but i think the objectionwould carry forth anyway. they're far more acceptingof truck-based adulticiding. but i think, important for localcontrol programs, that's based on our communication andtheir strong trust in us that this is a diseaserisk-based decision that's made to balance potential harmand potential benefits. so, that's goingto look different.
a challenge going intothe year while we plan to substantiallyexpand our work is that, when the city itself conductsthe work, things go better. and in any effort totry to expand rapidly, that becomes a challenge both interms of resources and in terms of being able tomanage the burden. there is very poorpredictive power year-to-year about what we can expectin terms of positivity in mosquito pools and theextent of the actual level
of response thatwe need to have. so, we maintain a robustsurveillance system, and we have staff that we borrowfrom other programs as needed. we do provide a great dealof reassurance to the public by using our syndromicsurveillance system and our poison controlcenter to track in near real time whether ouradulticing program results in inadvertent exposuresor negative health outcomes at least as we candetect from those systems.
we're happy to say that,in the last decade, we have not had anyadverse outcomes. and that's importantgoing into this season where everythingwill be expanded. and finally, as you'veheard all morning long, community engagement is criticalto all of these efforts. so, we have had avery robust response to date in terms of planning. i'm going to -- these aresort of elements of many
of your states and cities that are responding,as well as the cdc. this slide is a bit out of date. this dates to themiddle of march. but so far, just to give youa sense, we've spent well over $3.5 millionin preparation. we've conducted wellover 1,600 lab tests at our public health labwith human specimens. we've detected 25zika infections
in returning travelersto new york city, three of whom areamong pregnant women. and we expect to bedoing much, much more. so, there are a varietyof factors that we're really thinkingabout in terms of mounting, and writing, and publicizingwhat will become a final zika control plan, or atleast an intro on one for this coming mosquito season. and i want to kind of talkquickly about what those are.
first, i want tobe really clear, new york city does not haveaedes aegypti mosquito. in 15 years of mosquitomonitoring, we've tested over 1.2 million mosquitoes. we've speciated them. we've never found aedesaegypti; understanding that things can change. but we're going intothis anticipating as aedes albopictuscontrol program.
each year, we havehundreds of cases of dengue and chikungunya cases diagnosedamong returning new yorkers who have traveled. that gives us some reassurancethat there has never been a case of locally-transmitted dengueor chikungunya in new york city. and so, we're hopeful that going into this season we will notsee established populations of infected mosquitoeswith zika. we know going into this season
that public concern isfar greater for zika than it has ever been for westnile virus for obvious reasons in terms of the populationat risk and the consequences. and in terms of makingdecisions about how and where to do control strategies, we'rereally conscious of the fact that most infectionsare asymptomatic, suggesting that the transmissionto a local host can occur without the knowledgeof the location. local transmission could occur
without prior detectionin mosquitoes. human testing is limited, drivenby concerns about pregnancy and emergence of symptoms. so, zika could be transmittedto mosquitoes in areas where we do not havepeople being tested. and the infectious period inany person often passes prior to the availabilityof test results with which we canmake spray decisions. these i won't go over in detail
because you've heardthem all morning long. but the fact is that aedes looksquite different than culex does. this is a side-by-sidemap, for example, of the known distribution onthe left of aedes albopictus in new york city, which we havenon-historically controlled for. compared to the right,which is culex pipiens, one of the leading vectors of west nile virusin new york city. and you can see thatthere is, you know,
they're largely inverseof each other. so, we will -- we know thatour program, as it takes shape, will have a variety of elementsthat will be increased outreach and complaint response tocontrol breeding populations, increased distributionof repellant. we'll be dealing with many novelneighborhoods in new york city in an aedes control program. we will be deployingnew traps to improve at least our estimation ofthe magnitude of the problem
with aedes mosquitoes. and we will be usinga new arsenal of pesticides includingmethoprene, which is an insectgrowth regulator and a newly-registeredproduct in new york state. duet, which we thinkto be effective against aedes duringnighttime spring because of the exciting agent. we'll be using some newground larviciding techniques,
and we will be modifyingour decision logic for pesticide applications. no longer do we expectto use disease-based or mosquito positivityto really guide it. it will be driven principally by the presence ofaedes mosquitoes. and we do expect there tobe a lower threshold overall for community-level response than we have forwest nile virus.
so, thank you very much. with that, i'd like toinvite dr. shah to join us. >> good morning. it's great to be here today. i just wanted to first of allthank the cdc and sponsors of this great summit, andalso partners that are in the audience, many ofwhom it's great to connect with today, and certainlymy fellow panelists. so, i'm going tospeak very quickly.
so, although i'm from texashere, i'm going to do my best to go as fast as i can. so, please bear with me. responding to zika; a localtexas public health perspective. so, as was mentionedby dr. schuchat, i'm the executive director forharris county public health and environmental services,the county health department in harris county, texas. we're home to the third mostpopulous county in the us.
which is spread over,interestingly enough, a geographic area that's largerthan the state of rhode island with 1,778 square miles withfour times the population. we are diverse in everysense of the word, and growing in everysense of the word growth. and are home also to anincredible amount of resources with the largest medicalcenter in the world, but certainly haveour challenges. mosquito control
in our community is very muchgrounded back in the 60's with st. louis encephalitis. the harris county voters voted in a mosquito controldistrict in 1964. it went into operation in 1965. and last year, we celebrated 50years of "fighting the bite", if you will, primarilyagainst the culex mosquito. and have gone through ournationally-recognized program a number of milestones, includinga 1985 characterizing aedes
albopictus first timein the continental us in the early 2000's whenwest nile virus was really where we needed to start toshift much of our attention. but over the last couple ofyears, we've started to now with dengue and chikv, and alsowith zika, have started to move into the realm ofthe aedes mosquito. and so, you can see someof the real activities that are very much aboutwhat we've been doing for the last 50 years.
and i think it's reallyimportant for us to remember that a lot of this is goingto continue to be in play as we think about the fight against the aedesmosquito outside of the avian surveillancepiece here that's listed in the top left. so, our approach toaedes is very much about knowing what'shappening with the vector. and as you can imagine, idon't know how many folks
in the audience have been totexas, but we do have a climate that appears to like mosquitoesor helps to breed mosquitoes. and that's something thatreally is something that we need to be aware of and alsounderstand as we shift from primarily a culex-basedmosquito control program to also the incorporation of the aedes mosquitoespart of what we're doing. and that means emphasizinga number of different things that you've heard all morningaround source reduction,
personal protection, andcertainly public education. but what we're also doing is toreally bring those principles of one health andhealth equity as part of our approach to aedes. and that really isvery important for us. so, from a healthequity standpoint, we know that if we go to certainsegments of our community and say that it's easy, forexample, to just get screens on your windows orrepellants and just go out
and do this, it's really nuance. it's not as easy incertain populations that we have in our communities. and so, we need to reallyunderstand the socioeconomic factors, literacy,access to care, access to health information, et cetera that reallyis in play with that. and then we would befoolhardy at our department if we did not utilize some
of the fantastic human healthvector control and animal health that we have at our departmentwe're fortunate to have. so, to integrate those togetheris really part of what we do, and certainly part of ournew multidisciplinary team that we have put in place so that we can do sometargeted interventions depending on what's happeningin our community. but it's not just theory, it'sactually theory to practice because january 11th we hadthe first texas traveler case
of zika. and so, it was very early on. and so, obviously,we were working on this even beforedecember was over, and the holidays, et cetera. because from our standpoint,it was really that we needed to be very cognizant ofwhat was happening not from a theoretical standpoint. but very quickly, we werein the midst of response.
and that response meant thatwe were getting international and national attention. we had to come very up tospeed on what was happening with zika almost before wegot to the point of being able to even look at some of theresponse levels that you see that are highlighted here. so, level 4 all the way tolevel 1 for us is really about how do we go fromtravel-associated zika where there's no localtransmission all the way
up until you have widespreadzika from a local transmission, or that you have widespread zikathat's found in your mosquitoes. and certainly, ourresponse team that i have to really give an incredibleamount of kudos to was a part of this real opportunityof coming together in a multidisciplinary approach. and i would really say that multidisciplinary approachis the only way and the best way to go about doing this.
the other thing i wouldjust point out now is that, as we look at theselevels, there are going to be incredibly differentkinds of responses and resources that are going toneed to be positioned as you get into those levels. and so, from thatstandpoint, mosquito control and communications are where i'mgoing to focus on very quickly. from a mosquito controlstandpoint, obviously you've heardthat we have limited data
from a historical standpointon the aedes mosquito. and so, we are expandingour surveillance efforts from a trapping standpointwhile we're also looking at how do we do predictivemodeling as part of that. and key metrics for ourmapping are listed here. but i have to be honest, it'sreally how do you layer all that information together in a real focused manner whilewe also beef up training, equipment, materials,and partnership
with our communityand our partners. these are some pictures ofour traps as you can see. there are some trapsthat are very much about aedes mosquitoesprimarily, others that sort of get both, others thatget the culex mosquito. and we're also looking at theago trap that was mentioned by dr. kass to really appreciatewhat are the kinds of things that we can do so we have abetter idea of what's happening with the aedes mosquitopopulation
in our vector species. and it's not justabout the traps. right? it's not thedollars to pick up the trap. it's the person on theright that you see. it's the people that haveto go pick up the traps, and the testing materials, etcetera that really are key areas of how do you increaseyour surge when you have additionalactivities that are a part of that.
and you can see this withour mosquito control areas that we have divided upour 1,778 square miles into 268 mosquitocontrol operational areas. and you can see inyellow and blue where we have traditionallybeen doing trapping for the culex mosquito,but now adding in what is really verymuch a part of our plan for the aedes mosquito. and i have to say that thereare some resources constraints,
again, not just about the trap,but actually on the resources to actually help withthe increased workload that goes along withthe trapping. let me segue intocommunications and say that this is a key componentthat you've all heard about today, and soi won't belabor this. but to say that as welook at our campaigns and the real partners that arepart of this, we see the media and really a number ofdifferent agencies that are part
of what our strategyis moving forward. that also means we need tobe culturally appropriate and we need to bein the languages that are a part ofour community. and we need to bereally thinking about how we can bestengage our federal, state, and local stakeholders. this is the point where i doa shout out to my colleagues at naccho, nationalassociation of county
and city health officials. as well as colleagues who arehere with the texas department of state health services. and a particular shout out tolocal health officials in texas with the texas associationof city and county healthofficials, taccho. because we all have towork on this together. we can't get throughthis by ourselves. and the other thing that iwanted to point out in this is
that social media and engagement of our community is anabsolutely critical piece of this. other focus areas -- and i,again, won't belabor this as you've heard thisthroughout the day -- are really around episurveillance and testing, healthcare provider/clinicianoutreach, environmental and veterinary public health,legal review and authority, and emergency preparednessand response.
and these are areas thatwe think are very critical to our multidisciplinaryapproach to the aedes mosquito. so, let me close withthe last two slides here about our response challenges. first, is that thesituation related to zika continues to evolve. i think a coupleof months ago none of us would be thinking wewere going to be talking about sexual transmission in theway that we talk about today.
and so, we have to stay humble, which i think is areally important point that dr. friedenmade this morning. that humility is such animportant piece of this. we do not have everythingfigured out around zika and the aedes mosquitopopulation, but we need to be continuallywatching what's happening as the situation evolves. "we also cannot spray ourway out of this situation."
that's a quote. it's my quote, soi put it in quotes. it's up there. [ laugther ] we can't do that, right? so, we have all the othersource reduction, and education, and personal protectionbecause this is really about not the truckcoming in the middle of the night that's goingto be able to get rid
of the culex mosquito. it's how do we bring theaedes mosquito on top of the culex-based approachthat we have already. and we need to have abroad-based platform of doing that so we have efficiencies and our logisticalissues are taken care of. and finally, i do want tomake mention of the fact that what dr. peterson mentioned about mosquito controldistricts --
our program, thougha great program, is 98% funded by local dollars. to me, that's provocative whenwe think about arboviruses and mosquito control activitiesin a community such as ours. and so, i just want to putthat out there as well. so, let me close with thislast slide that just -- this is a picturefrom 2005 katrina, an official icd form214 that i put in. it wasn't for widgetsand things.
it was actually forcommon sense. and, yes, i had alot more hair then. and it was not gray,it was black. so, i get that. but that is me. and i want to remindus that really the role of public health, andnot just public health, local public healthjust makes common sense. because at the end of the day,
health really happensin local communities. and this is a picture ofour zika response team. and i'm very proud ofthe work that they do, including dr. mustapha debboun who is our mosquitocontrol director who i really appreciatehis efforts with our vector activitieshere in houston, harris county. thank you so much. >> buenos dãas.
i echo my colleague's sentimentsof gratitude for the opportunity to present puertorico's work here today. and, umair, i will try togive you a run for the money. so, one of the most effectiveways to get protection tools in the hands of pregnant womenand those of childbearing age is through zika prevention kits orzpks like the one pictured here. in puerto rico, distribution hasbeen mainly through wic clinics. we're also just delivering theseto ob/gyn offices in the areas of active zika transmission.
additionally, we'rein conversations with drug store companiesto deploy zpks when women purchasepregnancy test kits. there have been variousiterations of these kits. but the constant componentsinclude insect repellant, preferably 25% deet,bed nets, condoms, and culturally-competenteducational materials. prior versions haveincluded thermometers and larvicidal dunks, butthese have been removed due
to mixed reception. some components are illustratedhere, as well as the map of the initial week of zpkdistribution in wic clinics and hot zones forzika transmission. one prevention activitythat has met with mixed success istemporary screening. many caribbean cultureslike to take advantage of the balmy, leeward breezes. thus, screening isnot widely used.
the plan has been toacquire various materials in relatively low numbers andprice ranges and pilot them, testing the viabilitygiven the different window, and door styles, andframe and wall surfaces. the kit picture hereis one example which was actuallynot very successful as staples do not tend towork in concrete walls. and duct tape is not veryresilient given the high humidity and temperaturesin the island.
as mentioned today by many ofmy colleagues, it is important to understand what are thecompetent vectors in your area. it is also important to understand insecticideresistance patterns. this information shouldhelp determine available and most effectivedelivery methods such as ultra-low-volumetruck-mounted spraying, indoor fogging, insecticidetreatment of curtains or bed nets, indoor and outdoorresidual spraying in the homes
of pregnant women that expressinterest and give consent to undertake theseactivities in their homes. in puerto rico, we arealso giving consideration to aerial spraying oflarvicides such as natural bti. however, we knowthat acceptability of widespread insecticide use in various delivery methods canbe an issue among the general population and the scientificenvironmental community. furthermore, it is importantto ponder rollout logistics,
to outsource or to use existingcontrol vector programs, how to engage high-riskpopulations and communities, how to design messagingon insecticide use and delivery methods, aswell as coordinate services and give consideration offederal and state regulations and permits and financing. much has been saidabout acceptability. are interventions acceptable? are messages culturallycompetent?
do they resonatewith your population? puerto rico has beendealing with aedes aegypti for over 40 years, to the point that some accept dengueepidemics as a fact of life. our population is knowledgeable as to what activities areeffective in mosquito prevention and control and do havepositive attitudes. however, these activitiesare not quite yet -- we're not actually there onundertaking those behaviors.
thus, with the collaborationof our cdc colleagues, we have undertakenbehavioral studies to understand what messaging or activities can help usactually affect behavior change. we'd also like to understandacceptability and usefulness of the zpks and theircomponents, what interventions arepregnant women comfortable with and willing to accept, andwhat messages work or not. this information has andwill be used to revise
and design messages andidentify potential spokespersons and champions onmosquito bite prevention. one message from pregnantwomen that is very clear is that they want communityinvolvement. it is also very important to have a strongcommunications plan and team, not only to address educationalmessages, but to communicate in plain language the spectrumof vector control interventions and the risk of sexualtransmission to assist also
in designing how to best presentrelevant surveillance data, and certainly to assist inhow to handle communications with the various media outlets. now, the next few slidesdo not necessarily address vector control. they address otherimportant planning and preparedness activitiesin any zika response, which were actually touchedon by our previous panel. epidemiology capacity andmodification or implementation
of surveillance systems areindeed necessary and very needed to address all theissues at hand. in our case, it wasvery relatively easy to modify our passivesurveillance systems for dengue and chikungunya toincorporate zika. now, this makes oursurveillance system one of passive arboviral diseasesinstead of siloed dengue or chikungunya systems. we also have a zika-positivepregnant women
surveillance system. however, as explained by dr.bell, it differs somewhat from the registryimplemented nationwide as ours is an active system where we undertakemedical record abstractions and follow-ups. it was very important toalso incorporate congenital microcephaly in our birthdefects surveillance system in order to understand and trackpotential adverse birth outcomes
associated to infectionsduring pregnancy. additionally, we haveimplemented a guillain-barrã© passive surveillance system to better document the truerelationship of gbs and zika. and lastly, as zikascreening tests for blood units hasbecome available, we will implement asurveillance system to track potential zikainfections associated to blood transfusions.
it is important to understand that these tests gobeyond the design and implementationof the system. but that all that comes alongwith it, education and outreach to clinical communities,preparing materials that clearly explain thepurpose of and how to report to the systems, retrainingkey hospital staff on critical activitiesjust as how to properly measurehead circumference
and body length in newborns. and also, in formingpreparedness plans for healthcare services. needless to say, theimplementation or modification of these surveillance systemscan stretch the epi capacity of any jurisdiction. so, planning on how to bestallocate limited resources is a must. another key component isthat of laboratory capacity.
we're fortunate to have thedengue branch in puerto rico. our strong partnershiphas places in a position to help validatethe rt-pcr trioplex, making us the first jurisdiction to have this veryvaluable and useful tool. this test allows us tosimultaneously test for dengue, chikungunya, and zikawith a single sample, reducing testingturnaround time for results, staffing needs, and costs.
rt-pcr technology will not beuseful however in the diagnosis of asymptomatic womenor individuals who are over seven days post-symptomonset. thus, testing for theseindividuals will require zika igm testing. which, as we have heard, is verycomplicated and time-consuming. it is also importantto understand that in jurisdictionsendemic for dengue, igm testing for dengue is alsonecessary and a higher number
of cross-reactivityshould be expected, adding an additional level ofdifficulty to interpretation of igm-positive results. and finally, for us in puertorico, it is very important to increase the rangeof contraceptive options for those women ofchildbearing age who do not wish to get pregnant. of particular interestare long-acting reversible contraceptives or larcs.
unfortunately, larcs do nothave a high uptake among puerto rico's women. so, we will be conductinga behavioral risk factor surveillance system surveyin the next few months to better understandwomen's preferred options and potential barriers. those results should guidefuture interventions among both men and women of reproductiveage and provide guidance to healthcare providers.
as stated by dr. frieden,we do not know how to prevent possible adversebirth outcomes related to zika, but we do know how to preventunintended pregnancies. and with that, graciaspor su atenciã³n. >> well, i'd like to thank allthe speakers and now transition to a brief questionand answer period. so, reminder, thatthere are microphones on both sides of the room. you know, we have heardabout coordination
and multidisciplinary teams. we've heard about building offof strong west nile programs and the criticalissues of health equity in vulnerable populations. and i think we also had a reallyrallying call to common sense. and so, i think you can seethe wisdom that is present at that local, state, orfrontline level and a chance for the audience to probea little bit further. jeff?
>> i'd like to thankall the panelists. my name is jeff engel. executive director ofthe council of state and territorial epidemiologists, one of the ngos representedhere today. one of our biggest jobs is toadvocate for our constituents. in my case, it is the stateand territorial epidemiologist who are responsible forsurveillance both on the human and vector side inthis response.
so, the concern is the reason44.25 million that was cut from the public health andemergency preparedness grant which actually funds thosesurveillance programs in the states and territories. and we understand thatmuch of that money is going to puerto rico, and weunderstand the need. and we're not faultingthe cdc either for that because they had no choice. so, my question to thepanelists is are you meeting
with your local federalofficials, federally-electedpeople, senators, house of representatives toemphasize the important need for the zika supplementalfunding? thank you. >> thank you, jeff, forthat insightful question. you know, what i would sayis that this is really one of the biggest challengesfor us. is that we have to remember thatfunding needs to be broad-based,
and broad-based meansarboviruses. but a number of public healthemergencies and preparedness for that epi response or,in the midst of a hurricane, the other activities thatare very much a part of that. so, on the one hand, we'resaying zika is really critical and we need to put resourcesthere, and so we're adding for additional dollars there. on the other hand, the otherhand of our body says, "hmm." but our broad-based platform
of emergency preparednessfunding is actually going to be cut. and it's a nonsensical --it does not get us further. and what we need to dois really be thinking about how do we havethe broad-based platform of funding while wealso accentuate funding and activities and policiestowards the disease of the day because obviouslythe other diseases and other activitiesare also a part of that.
so, yes, we are gettingthat message through. and any help that wecan provide for that, we would be happy to do that. >> i'll just stand bysaying that the advocacy that we're doing inwashington can only be helped by the local advocacy thatonly you're able to do. >> next question over here. >> hi. oscar again. i just replied, soit seems like --
so, i'll try to make itas quick as possible. and this is primarilyto dan and to umair. could you please explainthe infrastructure cost, the difference in what ithas cost your entity to shift from the regular allocationsfor west nile for production against west nile orsurveillance against west nile versus what you anticipatefor zika? for example, the change ofthe traps and the change of catch basin treatments orall those types of things.
so, is there any way you canarticulate that for the benefit of those who don'tnecessarily get that? >> thanks. it's a good question. and i would say, youknow, to be really candid, it's a working progress. and as you can tell from mypresentation, we're working off of a lot of uncertainties. we don't know howmany there are.
we don't know whetherwe're going to, you know, ultimately arrive at a place where we have localtransmission, either individualcases or clusters. we don't know a lot. so, i can say a coupleof things. the first is our preparednesswork is really built off of the infrastructurethat we have from the phep grantsand other activity.
that's cost us, as i mentioned,sort of over $3 million in staff time justto kind of manage all of the response mostly on theclinical and the testing side. we are building estimatesright now of what our programwill look like. and we're imaging tryingto staff up at level that would allow us to atleast sort of treat and respond to large aedes populationswith many people at risk, many people returningwith zika, and a scenario
in which we anticipate localtransmission hitting somewhere in the continent ofthe united states which influences the levelof concern and panic. and we think it'll cost us, youknow, on the order of about $5 or $6 million additionallya year in new york city. >> thanks, oscar,for that question. you know, for us, thechallenge is very similar to what dan just mentioned. it's a real conceptof the unknowns.
there's so much we don't know. we don't know, as imentioned, the response levels. are we going to stay inresponse level 4 for six months? two months? eight months? twelve months? two years? we don't know whatthat's going to mean. and that slope really helpsdetermine how much funding
and resources thatwould be in play for us. we're estimating -- andany estimate is actually -- i think, honestly, the momenti put a number out there, i'm going to regret that ieven put a number out there. so, maybe i shouldn'teven say what -- yeah. yeah, he started. so, i would say about a half of what he just said iswhat we've been estimating. but the real challengeis that a lot
of our daily work has nowbeen moved to the side and shifted to other activities. so, you see up therei've got twitter. i tweet. i'm one of thedocs out there that tweets. @ushahmd. no plug here. but just to let youknow, is that a lot of my tweets right now arereally very much about zika. a lot of my communicationsfolks are sending out information about zika.
a lot of my epidemiologistsare working on zika. the real outreach to ourclinicians and our health alerts that we're sendingare about zika. so, what it's doing is thatit's starting to become -- it's really pervadingthis sort of -- becoming pervasive throughoutour activities throughout the department. and so, it starts tobecome harder and harder to quantify the delta
over broad-basedemergency preparedness and response activitiesin addition to the surge that we're doing with zika. but i would say just about half of what he said is probablya good ballpark for us. thanks. >> yes. sarah conte fromthe department of health and human services in raleigh. thank you for having us.
two things that i'm nothearing and i wanted to bring up is hopefully some allocation of funding specificallyfor emr upgrading. that's something that westruggle with in north carolina. we have lots of localhealth departments. and to go back intothose systems and add the zika question or any other additional questionis very expensive for them. so, that's my one comment.
the other, i likewhat i just heard from dr. shah; was social media. so, we're talking about apopulation of childbearing. you're talking abouthigh school. you're talking about college. you know, we need to get outthere and get in social media. because if we can educate havinga daughter that's just away at college for the firsttime, these are things that they educate themselves
and that i've actually heardher come back and say to me. "so, tell me about zika, mom." and that's okay becauseit's important to educate our obstetricians. but my daughter hasn'tseen an obstetrician yet. so, she might notget that information. so, i think thoseare important pieces. i know that i'veseen the who app, and also the americanacademy of pediatrics app.
but i don't see my daughtergoing to subscribe to that app. so, i think those are tworeally important things that we need to think about. >> having spent the pastfew weeks doing things like facebook, and googlehangout, and tumblr talks with amy pope including thespring break college newspapers, i think there is an effort toget our communication messages to a diverse group of folks whoare traveling, or folks who are at risk for unintendedpregnancy,
or of course theclinical community. i do wonder if some of thelocal and state folks want to talk a little bitabout other activities that you're doing in that arena. >> i would just add inaddition to, you know, in emphasis on social media, we'll be launching a new adcampaign in just a couple of weeks that'll be sortof both social media-based as well as print media.
but we have a lot of outreachthat's going on right now into communities in newyork city that travel. we have a tremendouspopulation of foreign-born. we know sort of theneighborhoods in which people are most likelyto be moving back and forth between the caribbean and latinamerica and south america. and so, there's been a lotof boots on the ground there as well doing site visits, community organizations,poster hanging.
that kind of thing. >> yeah. and i wouldlike to add that, in absence of largeamounts of money for large educational campaigns, social media tools havebecome very important. and that's one that we haverelatively easy access to. so, the department of healthhas been very adamant in pushing out social media messagingfor various populations, for the traveler population,for the local population,
pregnant women, the younger agegroups, and of course men on how to protect their partners frompotential sexual transmission. and we've been doing thisthrough facebook and twitter. of course they're in spanish,but you're welcome to visit. >> and we have -- and ibrought a "prevent the bite day and night", one ofour materials here. and we've shiftedfrom the real -- again, the nighttime activitiesof, you know, dusk and dawn and all the -- it's almost 24/7.
really that's whatwe're getting at. right? so, the challengewe're going to have, and i think is something we'regoing to eventually get to, is there will eventuallypotentially be fatigue when the messaginggets out there so much. and now, we're going to have toreally shift to different kinds of strategies sothat we can continue to emphasize theimportance of the message. and that i think is going tobe -- we're not there yet --
but i know that that issomething that we all need to be cognizant of as well. >> and i mentioned our socialmedia outreach in florida. facebook, twitter,flickr, youtube as well. try to do it using astandardized message and that's partly why wehave our advisory, alert, and emergency system that thoseare standardized triggers then that provides new informationand hopefully new attention to the issue rather thanjust sort of randomly putting
out messages to ourconstituents. >> and i think thereare some aspects of this that are quite similarto influenza work where, at different locations at thesame time, there are going to be different situations. and so, cdc is very committedto supporting consistent, evidence-based, you know, riskcommunication and core messages. but at the locallevel, you're going to have a different context.
and that's why some of thesetools are quite important. >> if i could just make one-- that's a great point. so, we often times say that weneed to have the same messaging. we actually need to haveconsistent messaging. it's very different. and i want to point out thatwe have a texas department of state health services partner with our new commissioner,dr. hellerstedt. they're really looking athow to communicate better
across the system, whichis the best way to do this. which then allows localhealth departments, local mosquito controlprograms, to really build into what the statewidemessaging is. and i've got colleagues herefrom dallas county and also from tarrant county, andaustin and travis county, and other parts of texas. and they're really very muchabout youtube and trying to get informationout and new ways
of really approachingwhat we're trying to do. and i think it's reallykey for us that we have that consistencyacross the messaging. >> okay, i'm gettingsome signals here. so, i do see a lot ofpeople at the microphone. so, i think we could take justone question from each side. i do want to mention thereare going to be opportunities in the breakouts and thelunch to probe deeper in many of these issues.
so, over here first. >> thank you. i'm lardos mokydo from tennessee. buenos dãas. i want to make a pictureof aedes albopictus. and i was glad to see innew york that you're worried about aedes albopictus. so, lessons from tennessee,we have had recent emergence of la crosse, andrecent being 1997.
and this emergence has alsooccurred in north carolina and west virginia, areasin the appalachian regions, which are impoverished areas. and we believe thatit emerged there because of aedes albopictus. so, we have a mosquito that hascontributed to the emergence of a disease that we'vealready seen with respect to zika virus specifically. in gabon, the outbreak therewas driven by aedes albopictus.
and in fact, the only mosquitoesthey found positive were aedes albopictus. there have been other examples of aedes albopictus beinginvolved in zika transmission. so, i think it's very importantto do aedes aegypti surveillance or surveys in various states. but at the same time, wealready have an important vector that we should keep our eyes on. >> i just want tomake a quick comment.
i think that, you know, we areworking under the assumption that it's a mosquito of concern. we don't know that it'sa competent vector. so, evidence to date hasdemonstrated they can acquire the virus. there's little evidence at thispoint to suggest it in settings in the continentalunited states. it may in fact bea competent vector, but i think it is rightto prepare for it.
>> last question here. >> bobby from key west. and my comment ismore than a question. but i would think that,while everyone was here, it's something that'sreally worth considering. that we have a veryrobust mosquito control in the florida keys. we have a good healthdepartment, i hope. the harris county has afantastic health department,
and you see they havean incredible mosquito control program. it is ironic that you havethose two elements and yet, in key west, we had an outbreak, a locally-acquired denguethat went for months. and then you seethe first zika case that was sexually transmitted. my point just being that itis the people that we serve that are living in thelocal areas that we've got
to make sure thatwe keep focusing on. and the thought that itneeds to be on a local level with consistent messages, and also when the resources arebeing thought, they need to be, "how do we get themto the people and how quickly dowe get them there?" like laboratory testing forlocal health departments. things like this. and the other comment ithink that you will see based
on our key west experience,and hopefully not in zika, but it's a long-haul issue. i wake up every day wonderingwhen they will have dengue again because everything was there. and the same thingcould be with dr. shah. so, just think local i guess iswhat i'm trying to point out. >> thanks so much. i want to just close thissession by thanking each of the panelists and remindingus that today is about planning.
there's a huge amountof expertise and experience in the venue. we hope that the next sessionsthat you have give you a chance to get even more detailedin your planning efforts, and we really do want tobe ready for anything. there's been nothing aboutzika that's been easy so far, and there has beena surprise a moment. so, i think that conceptthat we can't be complacent, we can't burn outour communities,
we have to be ready. people are expecting us to. but we can't overpromise abouthow easy this is going to be. so, i'd like to have you joinme in thanking the panelists.
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