By Susan Blumenthal, MD, MPA and Ladan Fakory, MPA
With as many as 500,000 spectators and more than 10,500 athletes expected to attend the Olympic and Paralympic Games in Rio de Janeiro this summer, the world is racing to contain the mysterious, mosquito-borne Zika virus that has infected more than 120,000 people in Brazil since 2015. Several athletes and journalists have already said they will not attend this year’s games. It’s no wonder why: The disease causes microcephaly, a rare birth defect – never before associated with a viral infection – that causes babies of some pregnant women, infected with the virus, to be born with underdeveloped heads and brains. More than 1,300 cases of confirmed microcephaly in infants born to mothers who were infected with Zika during pregnancy have been reported in Brazil. Another 3,300 cases are still being investigated. Earlier this week, the Centers for Disease Control and Prevention (CDC) revealed that there are currently 234 pregnant women in the continental United States who are infected with the Zika virus and 189 in the US territories. The CDC reports that three babies have been born in America with birth defects caused by the virus, and another three pregnancies ended in either miscarriage or termination where there were signs of Zika-related abnormalities. All of the cases reported in the U.S. were connected to travel to regions of the world with outbreaks of the mosquito-borne virus.
The likelihood of a woman who was infected with the Zika virus during pregnancy giving birth to a baby with microcephaly is estimated to be as high as 13 percent. With approximately 4 out of 5 people infected with Zika having no symptoms, researchers studying the outbreak in Colombia reported last week that even pregnant women who don't show symptoms of infection are at risk of having babies with microcephaly. Additionally, physicians are concerned that infants might experience other neurological damage and developmental problems as a result of in-utero Zika infection that could affect a child’s vision, hearing, cognition, and behavior. These alarming consequences led the World Health Organization (WHO) to issue interim guidance on June 7, 2016 that those living in Zika affected areas “be correctly informed and oriented to consider delaying pregnancy.” Adults have experienced an autoimmune disease associated with the virus called Guillain-Barré syndrome that can result in paralysis. To date, several people infected with Zika have died.
On June 14, 2016, the WHO convened the third meeting of the International Health Regulations Emergency Committee to assess the impact of Zika and concluded that the risks posed by the virus are not high enough to postpone or move the 2016 Olympic Games. Pregnant women are advised not to travel to Brazil for the Olympics. The Committee’s experts also restated the importance of the availability and use of insect repellent and condoms for athletes and visitors, intensified vector control measures, enhanced surveillance, risk communication, and clinical care. The WHO strongly advises people returning from areas with local Zika infection transmission to adopt safer sex practices, consider abstinence, and delay pregnancy for at least 8 weeks upon return, and 6 months if the male partner has shown any symptoms of infection.
With no vaccine or treatment for Zika, or indeed much knowledge about who is most at risk for complications of the disease currently available, 150 bioethicists, scientists, physicians, and public health professionals wrote a letter to the World Health Organization (WHO) on May 27, 2016 urging that the Olympic Games be postponed or relocated. They worry that some athletes and spectators will become infected while in Rio and then carry the virus back to their home countries, further spreading the disease worldwide. This would be of particular concern for countries where the virus is not endemic and for developing nations that do not have adequate health infrastructure to prevent the disease’s spread and where mosquito vectors exist for transmission. They argue that major sporting events have been moved before; for example, the Women’s World Soccer Cup in 2002 was relocated from China over concerns about the swine flu. In their letter to the WHO, these experts believe that just a few infected travelers in several countries or continents could result in a “full blown global health disaster.” Additionally, there is a “perfect storm” brewing in Rio with financial and politic problems that could impact the course of the Zika epidemic there.
However, other scientists suggest that the number of Zika cases will decline during August-September, the winter months in Brazil, when the Olympics are scheduled to occur. However, recent seasonal patterns for diseases, like dengue, carried by the same Aedes aegypti mosquito, suggest that while the Zika outbreak might well ebb during the summer, it will most likely not disappear entirely. Furthermore, given the effects of climate change, some mosquitos are thriving in winter months that are warmer than in previous years. Another concern expressed by some experts is that the Asian strain of Zika (believed to be introduced to Brazil in 2013 and subsequently to other South and Central American countries) appears to have higher rates of serious complications, including microcephaly and Guillain-Barré syndrome, as compared to the African strain. More research is needed on these observations, and on other aspects of the disease. In terms of concerns about Zika transmission in America, it is interesting to note that despite more than a million cases of chikungunya (a viral disease carried by the same mosquitos as Zika) reported in the Caribbean, Latin and South America over the past several years, this disease did not spread throughout the United States. Additionally, a report of last week’s number of cases suggests that the chikungunya’s incidence has declined dramatically over the past months except in certain countries including Brazil, Colombia, the Honduras, and Bolivia. This is likely due to “herd” immunity—a large number of people have been infected already-- and a drought in the Caribbean. Thus, given there have only been small localized outbreaks of dengue and chikungunya in the United States (mainly in the Southwest including Florida and Texas), despite larger outbreaks elsewhere in the world, this pattern of small outbreaks will probably be the case with Zika in America as well. However, we really don’t know for sure.
But what we do know is this: Tens of thousands of tourists packed into outdoor stadiums and event venues at the Olympics this summer is worrisome to athletes and spectators when there is a mosquito-borne disease at large. To address these concerns, the WHO and the Centers for Disease Control and Prevention (CDC) recently issued statements to reassure the public that changing or cancelling the location of the 2016 Olympics would not significantly alter the international spread of the disease. These organizations note that many people already travel to and from Brazil every month for many reasons, and that, since 2007, mosquito-borne transmission of Zika has been reported in more than 60 countries and territories worldwide and in 40 countries in the Americas alone. Ten countries have reported person-to-person transmission of the virus. According to Dr. Tom Frieden, Director of the CDC, “The Olympics would represent less than 0.25 percent of all travel to Zika affected areas.” He states, “So even if the Olympics were called off, we’d still be left with 99.75 percent of the risk of Zika continuing to spread.”
While the WHO and CDC statements provide general reassurance that the Rio Olympic games this summer do not pose an increased risk of Zika transmission given the sheer volume of travel that already occurs to and from Brazil, the actual risk of further Zika spread as a result of the Games is difficult to accurately predict. To address this issue, several epidemiologists have developed a mathematical model based on estimating how many mosquitos will be in Rio during the Games to determine the chance that spectators and athletes could be infected during this three-week period. Their preliminary model suggests a 1 in 31,000 chance of contracting Zika during the Olympics in Rio – that means 16 cases– as compared to a 1 in 11 million chance of dying in a plane crash or a 1 in 9,100 chance of being killed in a car accident in the United States this year. According to this mathematical model, keeping the Games in Rio would not change the course of the epidemic globally. Similarly, a San Paulo-based research group confirms this prediction, estimating that attendance at the Rio Olympics would result in a maximum of 15 Zika infections among the visitors. Given the public’s fears about contracting Zika at the Games, Rio’s Olympic organizers convened a briefing on June 7th, with the city’s chief medical expert emphasizing these results from the mathematical modeling --that Zika is expected to affect only an estimated 1.8 people per 1 million tourists –15 people--during the three weeks of the Olympic competition. According to the European Centers for Disease Control and Prevention, attendees are much more likely to experience food poisoning during the Olympics in Brazil than to become infected with Zika. A number of scientists also believe that if an international event were to have furthered the spread of Zika, it would have been the Carnival festivities in February when Rio was hosting a million visitors and when mosquito proliferation was at its peak.
However, other experts believe there are limitations to the statistical mathematical approach described above. It should be remembered that this public health issue is not just about the number of cases, but also about whether infected people traveling back to their countries might trigger a new outbreak somewhere in the world, especially in slum-dwelling environments where WHO and CDC precautions and preventive strategies may not be implemented .
Additionally some ethicists and scientific experts argue that core principles animating the Olympic Games provide a counter argument to convening the Olympic competition in Rio this summer under these circumstances. An article published in the Harvard Public Health Review quotes the International Olympic Committee statement: “Olympism seeks to create … social responsibility and respect for universal fundamental ethical principles.” If any Olympic athletes or spectators attending the 2016 games in Rio become infected with the virus and return to their respective countries and then transmit the disease to others, this would represent a violation of the Games’ principles of social responsibility, which if interpreted broadly, would include not spreading an infectious disease. These concerns are echoed by bioethicist, Dr. Arthur Caplan, who writes that the WHO is “betting on the weather, responsible behavior by visitors, adequate mosquito control and a low sexual-transmission rate by returning visitors. All are gambles.”
What is clear is that the ongoing spread and impact of the Zika virus is yet another wake-up call after the Ebola outbreak last year that infectious diseases pose significant threats to human health and international security. On February 1, 2016, WHO declared that the Zika outbreak was a Public Health Emergency of International Concern. Experts estimate that 2.17 billion people are living in tropical and sub-tropical regions, where Zika-carrying mosquitos can thrive. According to the WHO, as many as 4 million Zika cases are predicted in the Western hemisphere alone by the end of 2016. There is increasing concern that the disease could affect people living in the United States during the upcoming summer season. As of June 15, 2016, there have been 756 Zika cases reported in 46 U.S. states and Washington D.C. (none of which have been locally transmitted), and 1,440 cases reported in 3 U.S. territories, with 1,386 cases in Puerto Rico alone. The virus is a particular threat to Puerto Rico, where local transmission is occurring. It has been estimated that as many as 25% of people residing there may become infected with the Zika virus.
Thus far, local transmission of Zika has not occurred in the continental U.S. states. However, U.S. officials are gearing up to deploy “rapid response teams” of 10-15 experts to any community that has even one case of infection to help local authorities monitor cases, perform laboratory tests, and increase mosquito control efforts. States considered most vulnerable to Zika transmission during the summer months include Alabama, Arizona, California, Florida, Georgia, Hawaii, Louisiana, Mississippi, and Texas. On June 14, 2016, an Interim CDC Zika Response Plan, a step-by step emergency plan, was released, and on June 13, 2016, applications were due to CDC to apply for $85 million in funds to fight Zika in communities. If local transmission of the virus occurs in North America, the Aedes aegypti mosquito would likely be the primary vector in urban areas and southern U.S. states along the Gulf Coast, whereas the Aedes albopictus mosquito could play a role in transmission due to its distribution as far as New England and the lower Great Lakes. The global transportation of cargo and travel by people are largely responsible for introducing these mosquito vectors across countries and continents. In addition, environmental changes including urbanization, dam construction, deforestation, and rising temperatures linked to climate change have increased the number of locations around the world in which these mosquitos can thrive. That’s why intensified efforts are underway to fight this virus including the development of vaccines to prevent further transmission and rapid early diagnostic methods. An experimental vaccine for the Zika virus will begin human testing for safety and appropriate dosage in the coming weeks after receiving approval from the FDA. The vaccine works by priming the immune system to fight Zika by introducing genetically-engineered material that mimics the virus in the body. In animal studies of this vaccine, antibodies were developed that attacked the virus. However, confirming the safety and effectiveness of any Zika vaccine will require large scale studies that would not be completed until 2017. Additionally, in recent months, several rapid diagnostic Zika blood and urine tests have also received emergency use authorization from the FDA.
As with the Ebola outbreak last year, the ongoing Zika pandemic underscores the importance of prevention and public health preparedness in mitigating the spread of infectious diseases and promoting global health. Since 1976, as many as three new infectious diseases have emerged each year: HIV/AIDS, SARS, Lyme’s Disease, H1N1 influenza, Ebola, MERS, and West Nile encephalitis are just some of the most serious and headline grabbing ones. As of 2014, more than 346 infectious diseases were linked to 16% of all human deaths worldwide.
Given the urgency of Zika as a public health threat, the Obama Administration requested $1.8 billion to fight the disease. Alarmingly, the Republican majority in Congress did not approve its request. Consequently, on April 6, 2016, the Administration redirected $589 million in unspent funding to combat Ebola to fight the Zika epidemic. Escalating public concerns about the potential spread of the disease to America has resulted in Congress currently debating what level of additional funding should be provided to fight this disease. By investing in research (which has still not occurred at an adequate level) toward the discovery of a vaccine and antiviral treatments as well as building emergency preparedness infrastructure, human suffering and the long-term costs of caring for children with microcephaly, and people with Guillain-Barré syndrome and other health damaging complications of infection with the virus can be averted. Additionally, the results of increased knowledge about Zika should pay dual dividends to help fight other infectious diseases as well.
People can continue to debate where the Olympics should be held this summer, but Zika is a global problem regardless of where athletes go for gold this summer, a public health threat that requires more resources and research to eradicate. On May 6, 2016, UN Secretary-General Ban Ki-moon announced the establishment of a targeted “UN Zika Response Multi-Partner Trust Fund,” which will provide a rapid, flexible, and accountable platform to support a coordinated response to support the global Zika Strategic Response Framework and Joint Operations Plan in consultation with UN agencies, partners, and international public health experts. Donors will contribute to a central “fund” and an Advisory Committee will direct monies to priority activities and programs. This is an important step forward, but we believe and have proposed that this Zika Fund be expanded and established as a “Global Health Security Fund,” a permanent entity to support the international response to all emerging infectious disease threats now and in the future.
On May 20, the World Bank launched an innovative $500 million insurance fund to address some of this need. The new Pandemic Emergency Financing Facility (PEF) will help in the fight against pandemics in poor countries. In the event of an outbreak, the facility will rapidly release monies to an affected nation and qualified global first responder organizations. The fund creates the first insurance market for pandemic risk. The Bank estimates that if the PEF had existed in mid-2014 as the Ebola outbreak was rapidly spreading in West Africa, as much as $100 million could have been mobilized by July to limit the spread of the epidemic. Instead, resources did not begin flowing until about three months later permitting Ebola cases to increase by ten-fold during that period of time.
Last month, at the G-7 meeting in Tokyo, pandemic planning was a prominent issue with the group’s endorsement of the Global Health Security Agenda. The G-7 has reached out to more than 70 countries to assist them in implementation of the WHO International Health Regulations. However, only about one-third of nations globally have the resources and public health infrastructure to respond effectively to public health emergencies like Zika creating vulnerabilities worldwide. That is why pandemic planning and response is essential with coordination of efforts, robust early detection methods, disease surveillance, and reporting systems, as well as investments in new vaccines, treatments, and prevention strategies. Community education and mobilization is critical, as well as creating a Pandemic Response Corps of trained health professionals, lab technicians, and other health providers, who can be rapidly mobilized when an outbreak occurs anywhere in the world.
The bottom line: focusing global attention on where the Olympics should be run this summer while failing to commit the necessary time, money, and action to combat the Zika virus is not a winning strategy. Throughout history, infectious diseases have killed more people than wars, making them powerful international enemies and decisive shapers of history. They remain clear and present dangers to human health, economic development, and national security in an interconnected 21st century world, and we must remain vigilant against them. That is why a medical marathon is needed, making significant investments now to strengthen the scientific knowledge base, developing new global health technologies including rapid testing methods that can be deployed in combination with proven public health practices, as well as strengthening health systems with a coordinated national and international response. These efforts will enhance our ability to fight Zika and other emerging infectious disease threats more swiftly and effectively, moving from peril to progress in the years ahead. Intensifying public concern about the spread of the Zika virus worldwide underscores that microbes are ticking time bombs against the health of humanity and failure to fight them is not an option.
Susan Blumenthal, M.D., M.P.A. is the Public Health Editor of The Huffington Post. She is a Senior Fellow in Health Policy at New America, Senior Policy and Medical Advisor at amfAR (The Foundation for AIDS Research), and a Clinical Professor at Tufts and Georgetown University Schools of Medicine. Dr. Blumenthal served for more than 20 years in senior health leadership positions in the federal government in the Administrations of four U.S. presidents including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women’s Health, and as Senior Global Health Advisor in the U.S. Department of Health and Human Services, where she focused on global health diplomacy. She also served as a White House advisor on health. Dr. Blumenthal was involved in the U.S. response to bioterrorism with the anthrax attacks in 2001. She has provided pioneering leadership in applying information technology to health, establishing one of the first health websites in the government (womenshealth.gov) and the “Missiles to Mammogram” Initiative that transferred CIA, DOD and NASA imaging technology to improve the early detection of breast and other cancers. Prior to these positions, Dr. Blumenthal was Chief of the Behavioral Medicine and Basic Prevention Research Branch, Head of the Suicide Research Unit, Coordinator of Project Depression, and Chair of the Health and Behavior Coordinating Committee at the National Institutes of Health (NIH). She has chaired many national and global commissions and conferences and is the author of numerous scientific publications. Admiral Blumenthal has received many awards including honorary doctorates and has been decorated with the highest medals of the U.S. Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. Named by the New York Times, the National Library of Medicine and the Medical Herald as one of the most influential women in medicine, Dr. Blumenthal was named the Health Leader of the Year by the Commissioned Officers Association and as a Rock Star of Science by the Geoffrey Beene Foundation.
Ladan Fakory, M.P.A. is a Health Policy Fellow at New America in Washington, D.C. She received her Master’s in Public Administration from Harvard University, John F. Kennedy School of Government. She has 11 years of health experience across the U.S. Department of State, U.S. Agency for International Development (USAID), and Walter Reed Army Institute of Research (WRAIR), where she focused on HIV/AIDS prevention, maternal and child health policy, global health diplomacy, and the Millennium Development Goals (MDGs).
An earlier version of this article was published in the New America Newsletter on June 9, 2016.