As you may have heard last Friday the Centers for Disease Control and Prevention (CDC) updated the number of reported pregnant women infected with Zika in the United States and its territories. That pregnant women in the United States had Zika wasn’t exactly news, but the new number was. As of May 12, 2016, a total of 279 pregnant women are being tracked through various surveillance systems. Of those women, 157 are living in the United States and the District of Columbia, and 122 are living in the territories. This is a huge spike, in fact, it triples the number of cases since the last report.
This increase is staggering, but the reason isn’t necessarily because of an increase in new cases (although that is a part of it), the primary source of the increase is from a change in the case definition of “Zika infection.” This has a lot of people scratching their heads, how can you change the definition of an infection, you either have it or you don’t, right? Not necessarily.
In epidemiology case definitions are used to classify cases of a disease into one of three categories: suspect, probable, or confirmed. This helps keep track of cases in a more standardized way and to understand what tweaks need to be done to the surveillance system in order to catch as many true cases as possible while minimizing false positives. For example, if a certain infection can only be confirmed through laboratory analysis and too many cases are being classified as suspect because there aren’t enough labs with the ability to test for the infection, then it may be necessary to ramp-up laboratory capacity. This is what’s happening with Zika.
Speaking of ramping-up laboratory capacity, the United States Congress has been debating whether or not to fund the public health response to Zika and to what degree. Back in February, President Obama made the formal request to Congress of $1.8 billion dollars to launch a coordinated public health response to Zika here in the United States and abroad. Congressional response was tepid, to say the least. Appropriation funding bills originate in the U.S. House of Representatives, which right now isn’t all that inclined to cooperate with President Obama on much. Three months later, the request has not been approved, and only a watered-down appropriation has been approved by the House but not yet discussed by the Senate.
Some of the reasons given by the House of Representatives for not fully funding the request have ranged from lack of accountability for the way the money is spent, to the fact that not all the money used for the Ebola response has been used-up. Others have pointed out that there is already money allocated for general emergency responses (in public health and otherwise) that could be re-directed by the President toward Zika. There are also some fiscally conservative legislators (on either side of the aisle) who have stated that they will not support appropriations for a Zika response unless and until cuts are made elsewhere in the budget to make up for the money spent.
This type of wrangling and debate would be healthy (no pun intended) in other circumstances, but it has left a public health emergency go unchecked for far too long. Essentially America is on the train tracks, public health officials have warned congress about the oncoming train, and the House has debated the merits of spending the money to move us off the tracks.
According to the 2016 federal budget, about $3.9 trillion dollars will be spent by the United States government in this fiscal year. The request is for $1.8 billion dollars, or 0.05% of the total US budget, which for the individual taxpayer translates to an additional $8.19 (or $3.13 per capita).
So what exactly would that $8.19 buy, that the U.S. isn’t already doing, to fight Zika? As I mentioned before laboratory capacity needs to be ramped up big time. Communications need to be funded in order to explain to the public what Zika is and is not, how to avoid it in particular and how to prevent mosquito bites in general. Then there is the funding needed to provide adequate supplies of mosquito repellent, treatment for standing water (e.g. ponds and reservoirs), and any other supplies to control mosquitoes. Last but not least, all of the medical equipment, medication and training that will be needed to track Zika cases, especially pregnant women who are infected.
If nothing is done now to slow or stop it, Zika has the capacity to dramatically increase the number of children born with microcephaly. Microcephaly is a condition in which the brain of a developing fetus or a newborn does not fully develop. This leads to children being born with abnormally small heads, developmental delays, and neurological disorders. In adults, Zika has been associated with Guillain-Barré Syndrome (GBS), a condition in which the immune system attacks the peripheral nervous system. This leads to generalized weakness in mild cases and total body paralysis in the most severe cases. While many people who acquire GBS recover, some will have life-long complications such as muscle weakness and trouble moving.
Perhaps the most discouraging thing about the situation with Zika is that it is a slow-moving disaster coming our way that public health officials, like myself, have been powerless to stop due to the lack of funding. The virus itself was first discovered in Africa in 1947, but it wasn’t until the beginning of this century that it started its march across the Pacific. By 2014, it was in the South Pacific, and it arrived to the Americas in 2015. While cases of Zika along with its associated cases of microcephaly and other neurological conditions were on the increase in Brazil and Colombia in 2015, public health agencies in the United States and elsewhere were focused on Ebola. Still, in February, President Obama asked for enough money to respond to Zika in a way that would slow it down or stop it. Yet, here we are in late May at the cusp of mosquito season, and there is no action from Congress so that state and local health departments don’t spend all their cash designated for other public health activities.
Yes, there is a lot of waste in the federal budget, and there are plenty of places where cuts can be made in a way that is sensible and where the least number of people would be affected. On the other hand, Zika is a public health emergency. It has the capacity to overwhelm our healthcare infrastructure in the short-term with those who fall ill, in the mid-term with pregnant women who need to be evaluated and followed-up after being infected, and in the long-term with microcephaly and GBS cases. From every perspective, whether or not to spend 0.05% of the budget should not be taking this long when there are already cases of Zika in the U.S. and its territories with no signs of stopping. One can only hope that lawmakers see this for what it is – a public health emergency of international concern – and do their best to meet the funding needs of the thousands of public health workers and researchers who are, once again, stepping up to protect the public’s health. I will gladly spend $8.19 to stop Zika.