“we are not finished with Zika… It very well could come back.” Are we ready?

In 2014, I suggested several anchor principles for Ebola preparedness in New Jersey, as hospitals of all sizes and scope “marketed” their Ebola readiness, only to learn that it took well over 20/ 25 full time staff to care for one Ebola patient (and 50 in Dallas!).
These recommendations included that every hospital that certified its Emergency Room as ready for Ebola be subject to at least three separate drills using a standardized form, and then be subject to random “secret shopper” inspections; that anyone with a confirmed or suspected Ebola diagnosis be immediately transferred to a regional center hospital designated by national standardized criteria which could demonstrate that it has sufficient nursing staff “volunteers” to care for a least five patients round the clock; and that isolation hospitals be readied for instant activation, whether a closed hospital prepared for Ebola now and standing by, or a “virtual” hospital ready-to-go in military fashion.
Also there was a need to minimize Ebola patients walking into an ER unannounced, and suggested a statewide 800 number be established so patients can call ahead and be transported by a prepared ambulance team and taken to a regional center.
The Federal government, later than sooner, did exclusively designate three national bio containment facilities hospitals as Ebola Centers.
In 2016 I suggested that similar organizing principles were urgently need to be established for tiered Zika hospital preparedness by designating Zika Regional Referral Centers. More specifically:
1. There should not be an automatic default to just designating Ebola Centers as ZRRCs, although there is likely to be significant overlap.
2. Zika Centers should be academic medical centers with respected, comprehensive infectious disease diagnostic/ treatment and research capabilities, and rigorous infection control programs. They should also offer robust, comprehensive perinatology, neonatology, and pediatric neurology services, with the most sophisticated imaging capabilities (and Zika-related “reading” expertise).
3. National leadership in clinical trials.
4. A track record of successful, large scale clinical Rapid Response.
5. Organizational wherewithal to address intensive resource absorption.
6. Start preliminary planning for Zika care out of the initial designated ZRRCs.
Zika protocols will be templates for are other mosquito borne diseases lurking on the horizon, such as Chikungunya, MERS, and Dengue.

Where are we today on readiness for Zika or other emerging viruses?

“Farewell, carefree days of summer. The number of people getting diseases transmitted by mosquito, tick and flea bites has more than tripled in the United States in recent years, federal health officials reported on Tuesday. Since 2004, at least nine such diseases have been discovered or newly introduced here…
New tickborne diseases like Heartland virus are showing up in the continental United States, even as cases of Lyme disease and other established infections are growing. On island territories like Puerto Rico, the threat is mosquitoes carrying viruses like dengue and Zika…
Between 2004 and 2016, about 643,000 cases of 16 insect-borne illnesses were reported to the C.D.C. — 27,000 a year in 2004, rising to 96,000 by 2016. (The year 2004 was chosen as a baseline because the agency began requiring more detailed reporting then.).. (A)

Mosquito-borne disease epidemics happen more frequently.
Chikungunya and Zika viruses caused outbreaks in the US for the first time.
Seven new tickborne germs can infect people in the US…
The US is not fully prepared
Local and state health departments and vector control organizations face increasing demands to respond to these threats.
More than 80% of vector control organizations report needing improvement in 1 or more of 5 core competencies, such as testing for pesticide resistance.
More proven and publicly accepted mosquito and tick control methods are needed to prevent and control these diseases.” (B)

““Mosquitoes—and the viruses that they carry—are pushing up the incidence of malaria globally and causing periodic explosive outbreaks of Rift Valley fever, which first brings on flulike symptoms but can turn into a severe hemorrhagic fever akin to Ebola. Bluetongue virus, a ruminant virus spread by midges that was once confined to tropical areas, has reached as far as Norway. Studies have shown shifts in cholera transmission with recent climate variability. As emerging diseases migrate to new areas, they encounter new species, making outbreaks even more difficult to manage.
Unfortunately, writes journalist Lois Parshley in her feature article “Catching Fever,” the common enabler for the movement of each of these ailments is human-caused climate change. As weather patterns wreak more havoc, a Pandora’s box of microbes enters new terrain, stressing global public health systems…
Such alterations are happening whether we want to use the words “climate change” or not. Whether we acknowledge the scientific consensus, demonstrated in thousands of studies over decades, climate change is both real and promoted by human activities. Coastal communities are being affected by rising seas, drought-prone areas are arid for longer periods and, as our report shows, infectious agents are taking advantage of these more extreme weather patterns.” (C)

“Texas Department of State Health Services released a report its first two travel related Zika cases in Williamson County this Spring.
DSHS said it serves as a reminder for people to be cautious as they travel this summer.
Austin Public Health got a jump start on mosquito prevention with a tire drive Sunday afternoon. Dozens of people dropped of extra and abandon tires that tend to lay idle and collect water.
Ashley Hawes, APH Research Analyst said when the department surveys communities who attract mosquitoes they realized many had standing water collected by tires, bird baths, and rain gutters.
“If we can educate people of simple ways they can get rid of water in their area they can help reduce mosquitos and hopefully reduce the amount of people who get sick from diseases like West Nile and Zika,” Hawes said…
Hawes said one spoon full of water can attract about 10,000 mosquitoes “ (D)

“Two years ago, the world was gripped in Zika panic as the mosquito-borne virus infected millions and spread across 80 countries. Officials declared a global health emergency and tourists canceled their tropical vacations. Thousands of babies were born with devastating birth defects after their mothers were infected in pregnancy…
Still, “we are not finished with Zika,” said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. “Even though when you look at the number of infections, it’s dramatically down, it doesn’t mean they’re going to stay down,” Fauci said. “You’ve got to be careful when dealing with vector-borne diseases. They have a tendency to cycle in and out. It very well could come back.”…
The U.S. Centers for Disease Control and Prevention recently deactivated its emergency response system for Zika that was launched in January 2016…
The future of Zika could look like the pattern of mosquito-borne West Nile virus, which hit highs 9,862 cases in the U.S. in 2003 and hasn’t reached those numbers since. Or it could be more like dengue virus, with four subtypes that reliably infect more than 1 million people each year in the Southern Hemisphere…
“We can’t totally write it off yet,” Lawrence said. “It’s still a potential problem for people traveling. There is always the potential for changes in the virus. I don’t think the story is over.” “ (E)

“Despite the powerful technologies that scientists currently have to characterize pathogens and treat the infections they cause, the course and consequences of epidemics are still a source of surprise. Modern tools of molecular biology have enabled researchers to tear apart the Zika virus and decipher all of its genes and proteins, to map the antibodies and blood cells it mobilizes in infected individuals. But we still don’t know why some people contract the microbe with little or no illness, at most mild fever and muscle aches, while others suffer Guillain-Barré syndrome, a life-threatening paralysis. And we can’t distinguish between those pregnant women whose babies will be born deformed and others who seem to escape the most devastating neurological effects of the virus…
While the spectre of Zika in the Americas is fading, it’s wise to stay vigilant. Some experts worry that new cases of Zika recently reported in northern Mexico could presage another outbreak, with subsequent spread to U.S. border states. Relying on herd immunity is shortsighted, since over time fewer people will be infected and the virus can gain a new foothold. Indeed, the geographic distribution of Aedes aegypti, the mosquito species that transmits Zika, is expanding. The insect is infesting unexpected parts of North America and Europe; a population of A. aegypti was recently found in Washington, D.C., and appears to have survived four consecutive winters. The steady creep of climate change could bring A. aegypti farther north, where there is no herd immunity.” (F)

“An international consortium of researchers has reported that an Ebola vaccine appears to provide volunteers protection against the virus two years after they were injected — encouraging findings both for the public health community and the vaccine’s manufacturer.
An earlier study, conducted in Guinea near the end of the devastating West African Ebola outbreak, showed the vaccine from Merck, which is given in a single shot, rapidly generated protection against the virus. But how long that protection lasts remained an open question.
A fast-acting, long-lasting vaccine given in a single dose would be an effective tool for controlling dangerous Ebola outbreaks. Vaccinating health care workers, for instance, could prevent the type of spread within hospitals that, in the early days of an outbreak, can turn a smoldering outbreak into a conflagration.” (G)

“Analyses of more than 400 mice in New York City found that they carried previously unknown viruses and antibiotic-resistant bacteria.
Mice that live in the basements of New York City apartment buildings — even at the most exclusive addresses — carry disease-causing bacteria, antibiotic-resistant bugs and viruses that have never been seen before, a new study from Columbia University finds…
The viruses included nine species that had never been seen before and others that have not been known to cause human disease, according to the study, published Tuesday in the journal mBio.
But in a second study focused on bacteria, the researchers detected some of the most recognizable disease-causing pathogens, including Shigella, Salmonella, Clostridium difficile and E. coli. The scientists also found antibiotic-resistant bacteria like those that have become nearly untreatable at area hospitals…
“They are a potential source of human infection,” said Dr. W. Ian Lipkin, the epidemiologist at the Mailman School of Public Health at Columbia who was the senior author on the study. “The real message is that these things are everywhere.”” (H)

“A baby believed to have contracted a drug-resistant strain of typhoid, hospitalized in Hyderabad, Pakistan in February. Nadeem Khawer/European Pressphoto Agency
The first known epidemic of extensively drug-resistant typhoid is spreading through Pakistan, infecting at least 850 people in 14 districts since 2016, according to the National Institute of Health Islamabad.
The typhoid strain, resistant to five types of antibiotics, is expected to disseminate globally, replacing weaker strains where they are endemic. Experts have identified only one remaining oral antibiotic — azithromycin — to combat it; one more genetic mutation could make typhoid untreatable in some areas.
Researchers consider the epidemic an international clarion call for comprehensive prevention efforts. If vaccination campaigns and modern sanitation systems don’t outpace the pathogen, they anticipate a return to the pre-antibiotic era when mortality rates soared.
“This isn’t just about typhoid,” said Dr. Rumina Hasan, a pathology professor at the Aga Khan University in Pakistan. “Antibiotic resistance is a threat to all of modern medicine — and the scary part is, we’re out of options.” “ (I)

“Members of a government ethics panel have renewed their criticisms of a controversial study in which volunteers are to be deliberately infected with the Zika virus.
In an article published this month in the journal Science, panel members called for the establishment of ethics committees to review the design of such human-challenge studies, which are sometimes used to test vaccines.
“There is no way to turn back time,” said Ms. Seema Shah, a bioethicist at the University of Washington who chaired the panel and is a co-author of the new paper.
“When you’re asking someone to take a risk that won’t benefit them but may benefit others in the future, you need to know two things — that proper protections are in place, and that it’s really going to move the needle.”
With funding from the National Institutes of Health, the investigators plan to inoculate participants with potential vaccines and then to inject them with small doses of the Zika virus to test the vaccines’ effectiveness. The N.I.H. has not yet decided whether the research will proceed.
The scientists leading the trial say it is necessary to prevent a future epidemic. But Ms. Shah and other bioethicists convened by the N.I.H. concluded in 2017 that the research had “insufficient value” to justify the risks.” (J)

“A public warning and call to action, the new book “Lyme: The First Epidemic of Climate Change,” by investigative journalist Mary Beth Pfeiffer, sheds light on a tick-borne disease that recently has emerged to infect hundreds of thousands of people in the United States each year…
“There’s a problem with how we manage Lyme disease,” Pfeiffer said in a recent phone interview. “People need to be aware that we have a long way to go before we get to the point where we can adequately diagnose and treat Lyme disease and other tick-borne diseases.”..
“[Lyme] has been in the environment for millions of years. That we know.” Pfeiffer said. “But it really exploded just as climate change was getting to the point where we were noticing differences in temperature, differences in snowfall, differences in the length of growing seasons and so forth.”
“I ultimately concluded that it was the first major epidemic to move about the planet as a result of climate change,” Pfeiffer said, well aware that some readers may disagree.” (K)

“The White House appeared to declare victory this week for an Obama-era initiative to stamp out disease outbreaks around the world even as it moved to scale back the program.
The National Security Council released a report on Monday trumpeting the achievements of the multinational Global Health Security Agenda, which helps low-income countries halt epidemics before they cross borders. The report “clearly shows how the investments made by taxpayers to improve global health security are paying dividends,” White House officials said in the announcement.
But the United States is set to dramatically shrink its contributions to the initiative, a point that the report omitted. The Centers for Disease Control and Prevention is preparing to narrow epidemic work from 49 countries to 10, an agency spokeswoman said.
That has alarmed health policy experts.
“It’s not a matter of if — but when — there will be another Ebola or Zika, and right now, the world isn’t ready,” said Dr. Thomas R. Frieden, who led the C.D.C. during the West African Ebola outbreak. “Many life-threatening gaps have been identified, but most of them haven’t been closed.” “ (L)

“The response to the Zika virus is fairly typical of both our strengths and weaknesses in dealing with infectious diseases, especially when they emerge. Existing drugs against other viruses were identified as potential therapeutics for Zika, efforts to develop a vaccine are underway and nearing completion, and the concern about Zika spurred some needed and valuable research. Those are encouraging signs, but these efforts were somewhat slow to get started and preceded by the usual complacency. We tend to close the barn door only after most of the horses have escaped.” (M)

(A) Tick and Mosquito Infections Spreading Rapidly, C.D.C. Finds, by DONALD G. McNEIL Jr., https://www.nytimes.com/2018/05/01/health/ticks-mosquitoes-diseases.html
(B) Illnesses on the rise, https://www.cdc.gov/vitalsigns/vector-borne/index.html
(C) Our Planet, Ourselves: How Climate Change Results in Emerging Diseases, by Mariette DiChristina, https://www.scientificamerican.com/article/our-planet-ourselves-how-climate-change-results-in-emerging-diseases/
(D) DSHS reports first 2018 Zika cases in Williamson County, by Natalie Martinez, http://www.fox7austin.com/news/local-news/dshs-reports-first-2018-zika-cases-in-williamson-county
(E) Zika retreats widely, but health experts remain concerned, by Blythe Bernhard, https://medicalxpress.com/news/2018-01-zika-retreats-widely-health-experts.html
(F) Is Zika Gone for Good?, by Jerome Groopman, https://www.newyorker.com/tech/elements/is-zika-gone-for-good
(G) In encouraging sign, Ebola vaccine appears to provide long-lasting protection, by HELEN BRANSWELL, https://www.statnews.com/2018/04/16/ebola-vaccine-lasting-protection/?utm_source=STAT+Newsletters&utm_campaign=189d05d6b0-MR&utm_medium=email&utm_term=0_8cab1d7961-189d05d6b0-149527969
(H) New York Mice Are Crawling With Dangerous Bacteria and Viruses, by KAREN WEINTRAUB, https://www.nytimes.com/2018/04/17/science/urban-mice-viruses-bacteria.html
(I) ‘We’re Out of Options’: Doctors Battle Drug-Resistant Typhoid Outbreak, by EMILY BAUMGAERTNER, https://www.nytimes.com/2018/04/13/health/drug-resistant-typhoid-epidemic.html
(J) Ethicists Call for More Scrutiny of ‘Human-Challenge’ Trials, by EMILY BAUMGAERTNER, https://www.nytimes.com/2018/04/20/health/zika-study-ethics.html
(K) Could Lyme disease be the first epidemic of climate change?, by By Aislinn Sarnacki, http://bangordailynews.com/2018/04/16/homestead/could-lyme-disease-be-the-first-epidemic-of-climate-change/
(L) White House Hails Success of Disease-Fighting Program, and Plans Deep Cuts, by EMILY BAUMGAERTNER, https://www.nytimes.com/2018/03/13/us/politics/trump-ebola-disease-cuts-global-health-security-agenda.html
(M) Cannot be complacent, by Stephen S. Morse, https://www.theweek.in/health/more/2018/05/05/cannot-be-complacent.html

    CURATED CHRONOLOGY OF 2016/ 2017 ZIKA CONUNDRUM & 2018 FLU EPIDEMIC

June 6, 2016
Former hospital prez says: Designate local Zika centers now. Medical experts do not know if, or where, or how much, or on what trajectory the Zika virus may spread across the United States.

August 13, 2016
The ER clerk asked me “How do you spell Zika?

August 19, 2016
With little gudiance about caring for Zika patients, hospitals are planning on their own

September 7, 2016
Hospitals are developing their own Zika preparedness models. Compare the Central Florida and Johns Hopkins approaches! Which template makes more sense?

September 29, 2016
All pregnant women with Zika diagnosed at community hospitals must be referred to academic medical centers for prenatal care!

May 15, 2017
EBOLA is back in Africa. Is ZIKA next? Are we prepared?

June 10, 2017
Study Findings: Five percent of pregnant women with a confirmed Zika infection.. went on to have a baby with a related birth defect

June 21, 2017
When I was a kid the only thing as scary as the polio epidemic was practicing getting under our desks for a nuclear attack…

July 18, 2017
In June WEST NILE was identified nationwide. Today it’s POWASSAN VIRUS. – ARE WE PREPARED FOR A SURGE OF EMERGING MOSQUITO AND TICK BORNE VIRUSES?

July 20, 2017
“Houston Braces for Another Brush With the Peril of Zika” *. But they are doing passive not active surveillance. IS YOU AREA’S HEALTH CARE SYSTEM PREPARED FOR A SURGE OF AN EMERGING VIRUS LIKE ZIKA?

July 27, 2017
Locally transmitted ZIKA case in Texas! Are we ready?

October 11, 2017
CDC deactivated its emergency response center for Zika.. The first probable locally acquired Zika case in 2017 has been confirmed in Texas….

November 7, 2017
a hand held device (was used) to measure the germ-count on some of New York City’s dirtiest surfaces

January 8, 2018
“We are arguably as vulnerable—or more vulnerable—to another (flu) pandemic as we were in 1918.”

January 11, 2018
In the ICU at Massachusetts General Hospital, nurses use Gatorade to combat flu-related dehydration (due to shortages of intravenous fluids)

January 15, 2018
The CDC postponed its briefing on preparation for nuclear war and will focus on responding to severe influenza

January 17, 2018
“Think hospitals are under a strain now, from a slightly bad flu season? Wait until a really bad one hits.”

January 20, 2018
Government Shutdown. “The CDC would furlough key staff amid one of the most severe flu seasons in recent memory….”

January 23, 2018
“..in a severe (flu) pandemic, the U.S. healthcare system could be overwhelmed in just weeks.

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