The Zika Virus: Emerging Data, Uncertainty, and Response


JOSH SHARFSTEIN: OK, why
don’t we get started. Thanks, everybody, for coming. I want to really think
Karen for organizing this. This is part of our
pop-up practice series. My name is Josh Sharfstein. If I haven’t met you,
I’m the Associate Dean for Public Health
Practice and Training. I used to be the city
health officer in Baltimore and the state health
officer for Maryland. And one of the things
that our office does is try to take some of
the different topics that are being learned here,
and kind of apply them to real life situations,
and kind of think through– what is it, like, not just to
be doing research on the topic but to actually be
responsible for it on the public health side. So that it’s going
to be the theme. I want to thank Beth Resnick
and Lainie Rutkow involved in the practice
office who helped organize this with Karen. And this is going to be
pretty interesting because we certainly found the topic
to rip from the headlines, as they say today, with Zika. And this is going to be
a little different then. How many people here went
to the forum last week and heard all the– good. So this is not going
to be a repeat of that. OK, that was a really
interesting discussion of kind of the cutting
edge of research. This is going to be
more of a dialogue about what it’s like
to be responsible, how do we think about this. And we’re going to
really try to engage you all in thinking about that
as well, so we’ll have plenty of time for questions. I’m going to be
kind of moderating, and my goal of
moderating is going to be to move things
along and really try to get a lot of interaction. Because we have some
really interesting perspectives that
you’ll be hearing. So the first speaker is going
to be Dr. Richard Brooks. Dr. Brooks is an internist who
went to medical school at Duke, and got a public
health degree from UNC, worked in clinical medicine
as well as teaching, and now as with the EIS
at CDC and eight months ago, came to Maryland. Maryland has a fabulous
infectious disease group in public health– really
some of the best people that I’ve ever worked with. And we will be talking
about international– and I know this is the
international health seminar, so we will be talking
about international. But I think it’s helpful
also to appreciate what’s going on right here in
Maryland because frankly, there are some countries,
internationally, that are kind of in a similar
situation, not all of them are Brazil. So, you know, it’s
sort of a spectrum of different experiences. So Dr. Brooks–
this is not going to be like the half
hour per person. And I’m a pretty
aggressive moderator, so we’ll cut off, you
know, the sound system– [INAUDIBLE] anyway. But I know that the people
that we picked really are interested in the
discussion and kind of thinking through the challenges. This is a very intense
serious challenge. I was in Bogota a
couple of weeks ago, and we had some meetings
with the health ministry and appreciating the intensity
of what is going on there now. I mean, when I was the health
secretary of Maryland when the Ebola, kind of,
panic hit in the US while there was a
real Ebola crisis. And to be in the center of an
actual evolving public health crisis is really an
intense experience, and it doesn’t just engage
your scientific investigative skills. It engages everything
because you’re dealing with people
who are very panicked. At one point, someone
said that the visual image was that he dreamt of him being
followed around by thousands of pregnant women
asking for help, and that’s kind of
the pressure that it feels like in that setting. So let’s start with Dr.
Brooks, and we’ll move on to our other great speakers. Thank you. RICHARD BROOKS: So how
do I advance the slides? JOSH SHARFSTEIN: Use the
forward arrow on the keyboard. RICHARD BROOKS: All
right, thanks, Josh. So yeah, I agree– I mean, sticking with a theme
that local is global and global is local. My goal here is to sort of
talk to you a little bit more about what I’ve been doing and
what my colleagues have been doing at the State Department
of Health over the last, about a month, in
response to Zika. I think part of the reason
we keep finding ourselves in the situations
we are in with Ebola and with Zika is because we
keep trying to approach these from a regional perspective
or an area perspective. And until we actually
step back and really see this as a global
responsibility, this is just going to keep happening. So my first call came
in on January 19. I got a call from
a 31-year-old woman who was 30 weeks pregnant. She had traveled to the island
of Martinique from January 8 to January 18– reported that she
was feeling well– had not had any symptoms. But again, keep in mind, she’d
only been back for one day. And she wanted some
more information on being tested for Zika virus. And I had, like,
literally, maybe heard about this a couple
of days before, didn’t really know a
whole lot about it. But did a little
research and told her I would get back to her
and ended up saying, well, CDC is
currently recommending that only people
with symptoms be tested, so we’ll be in touch. And we actually went on to go
back to her a few weeks later and test when they changed
the recommendations. So this is a slide in
no particular order. Again, just to give
you a little bit of an idea of all of the
different things that we at DHMH have had to
think about, talk about, create plans for
over the last month. So just to go through them. So who needs to be tested? Who doesn’t need to be tested? Do we follow the CDC’s
guidelines for testing? Do we develop our own
guidelines for testing? Are there situations
where we want to test outside of their
guidelines for some reason? Who actually physically approves
each patient for testing? And at that time,
testing was only being done at CDC, not
anywhere else, so we had to sort of create
all the logistical plans around getting those specimens
and sending them on to CDC. How do we keep track
of all these inquiries that are coming in? How do we keep track of
who’s actually been approved and who hasn’t been approved? How do we make sure that all
the clinicians in Maryland are updated on guidelines
and recommendations? How do we make sure that the
local health departments– every county in the city
of Baltimore in Maryland has a local health
department, and so they all need to be informed about this. They all need to be
on the same page. They all need to be making the
same recommendations following the same guidelines
that we’re applying. How do we ensure we’re keeping
up with all of CDC’s guidelines and recommendations? They were literally changing
on an almost daily basis. How do we make sure that
the local health departments are aware of their residents
who we’ve approved for testing? Because the state is
doing the testing, not the local
health departments. What specimens actually
need to be collected? Is it plasma, is it
serum, is it whole blood? What tubes do those go in? Once they’re collected,
do they get refrigerated? Do they get spun down? Do they get frozen? Where do they go in the lab? Does the provider’s
lab keep them? Does it go to the local
health department? Does it come from
the local health apartment to the state
health department before it goes to CDC? Who fills out the forms that
goes with the specimens? It’s a lot of stuff. How do clinicians get the
specimens transported? And then the question came
up, can we actually do any of the testing at DHMH? So fortunately, pretty
quickly, we have an amazing– I don’t know if you
guys are aware of this, but we have an
amazing public health lab in the state of Maryland,
really awesome people who are really– JOSH SHARFSTEIN: How many
people know where that is? It’s across the street. RICHARD BROOKS:
Yeah, it’s literally across the street, beautiful
new building, amazing. The people who work
there are fantastic. So that’s a great
resource for us. We’re very fortunate
to have that. So they are now doing PCR
testing and ELISA serology testing for Zika virus. So which patients need testing
of convalescent specimens? So everybody’s
acute now, we think, who are potentially
being tested. Who’s going to need
to go on and be tested in their convalescent
stage after they’ve finished having illness? How do we now communicate
all these results we’re getting back to the
providers who ordered them? How do we get it back to
the local health departments and make sure that
they’re aware? How are Virginia and
DC handling cases? What do we do if a
DC resident shows up to a provider in Maryland? What do we do when a
Maryland resident shows up to a provider in DC? How do we get those
specimens back and forth? Do we test DC’s specimens and
just send them the results, vice versa? Don’t know. How do we release our
results to the public? Are we telling them
additional details? Like which of our positive
cases are pregnant? Which ones are
travel associated? Which ones might be
sexually transmitted? Are we doing it on a
conjunction with when CDC releases their
state updates, or are we doing it
a different time? And then what’s our plan
for controlling the mosquito population when it starts
to come up in spring? What’s the Maryland Department
of Agriculture doing? Who’s handling media inquiries? What are we telling the media? What are we not
telling the media? So again, lots of questions,
lots of things to think about. And then I just also
wanted to list and sort of make everybody aware of a
lot of the different partners that we’ve been
working with on this. Because it’s easy to
forget that we are not just an entity unto ourselves. We have a lot of other
people that we have to bring into this situation. So it is a great opportunity. None of us in infectious
disease had really worked all that closely
with our colleagues in the Bureau of
Maternal and Child Health at the health
department, and this is a really unique
situation where we have an infectious
disease that’s potentially impacting pregnant
women and their children. So we’ve really come together
with them which has been fun. The Office of
Preparedness and Response. They’re the people who really
try to think ahead, and plan about the future,
and try to make sure that we’re responding to
this across all systems in the state. Maryland Department
of Agriculture is largely responsible for
the mosquito population vector control. Obviously, Centers for Disease
Control and Prevention. As I’ve already mentioned,
the local Maryland Health departments,
Maryland hospitals, and clinical providers. So we’ve sent out
clinician letters, I think, now three times to
over 19,000 clinical providers in the state of Maryland
and then Maryland universities and academic
centers like Johns Hopkins. And then finally, I
just wanted to list some of the ongoing activities
that sort of await us. This is what we are literally
doing like now, today, yesterday, tomorrow. So we have now had
over 270 requests for testing since
January 19, which is an average of 10
requests per weekday. So literally, like, every
day, my email just piles up, and there’s a whole bunch
of us on the email list. And everybody says,
I’ll take this one. I’ll take this one. I’ll take this one. I’ll just take this one. We call them back, and we
find out, we make approvals. And we fill out forms and
put them in the database. So just yesterday we had a local
health department conference call where we started the
process of transitioning some of the authority for
approving testing over to the local health department. So again, trying to diffuse
that responsibility a little bit on the most clear cut cases. Working on developing
a plan for vector control within partnership
with the Marilyn Department of Agriculture. Developing a plan now for
returning, like I said, all these results to the local
health departments, providers, and patients. So for every person that
gets tested for Zika virus, they’re automatically
being tested for Dengue and chickungunya as well. So there’s a PCR test
for each of those. There’s an IGM test
for each of those. So now for each patient you
have at least six results coming back for an acute patient. And then we are now
also testing urine because there’s some data that
PCR tests remains positive longer in urine, so that’s a
seventh test for some people. And then for people who
have positive Eliza’s, those specimens get sent on
to CDC for further testing. And then those results
come back to us, and we have to figure out how to
disseminate those results back to people. Improving our
communications with labs. As this huge data load
rapidly increases, we send a spreadsheet
back and forth with our lab twice a day
with newly approved people. They send it back with specimens
they’ve received and results that they’ve come up with. Improving our website
for Zika to make sure it’s well-designed, and
easier to read for people, and easy to find information. And then awaiting
further CDC guidance on sexual transmission. People probably have
seen the headlines that just came
out late yesterday afternoon when the CDC released
a health advisory notification that they are currently
investigating together with state health
departments like ours 14 additional cases of
possible sexual transmission. So that’s the
latest and greatest. And we’re all
trying to figure out exactly what to do with that. So hopefully that
gives you some idea of kind of what things
are going on locally. JOSH SHARFSTEIN:
Thank you, Dr. Brooks. That was terrific. It gives you a very different
sense of the problem from maybe the
research presentations that were there the other day. It reminded me when
we were dealing with Ebola I got a call
from an elected official, did I know that there was an
Ebola patient coming to the NIH in Maryland? They said yes. Did I know that they were being
flown into a special airbase in Frederick? Yes. Did I know that there would
be a convoy of police cars to take the ambulance to
NIH just in case there was any problem along the way? Yes, I did know that. What was my plan in case the
ambulance broke down en-route? So there’s really– it’s
a different perspective. Now, some people may hear
those kinds of details and go like, I would
rather be developing the vaccine in the lab. I totally respect that. But I hear those
details, and I think this is exciting to
be doing something like this right at
the front lines. And I’m very pleased. Our next speaker is Dr.
Castillo, a professor here, who has worked for many years
at the Pan American Health Organization. And he’s actually
doing a lot of work with health officials in
Latin America around Zika. He’s going to give
some comments on what is going through their
mind at this point in time. Thank you very
much, Dr. Castillo. CARLOS CASTILLO-SALGADO:
Thank you. Thank you very much. Let’s have the next– Well, thank you. Thank you very much. Again, I will be focusing
mainly in the public health surveillance in two specific
countries, Mexico and Colombia. I am very much in contact
with the authorities and the [INAUDIBLE]
epidemiologists there. One aspect is that
I will be focusing in the response from
those countries. With [INAUDIBLE] that has
been also an epidemiologist from the state of
Maryland, with that, seeing the tremendous increment
in the number of response about the reports in PubMed. I want to put the
context of what is happening with social media. And actually, the
technical report has been for many
years, almost decades, with a very normal, very
few reports and information. And last year and this year
has been a huge increase. You can see the Google
Trends information is also very flat for many, many
years, and then suddenly we have a lot of responses. What is important for us is
also to see these searches. And as you know, in our public
health surveillance classes we are monitoring now,
many of the tweets at social media for different
conditions, including Zika. Then we want to understand
the behavior of the response from the population too. And here is the tweets
and the searches. The concentration of
the Google searches has been basically in
some countries and cities. Particularly in
Venezuela, there is a lot of interest
about the Zika virus. With that, I will
be moving very fast on the way Mexico is
handling this outbreak. First of all, they emphasize
that the key monitoring now is Dengue. Dengue is the one that is
highly affecting the country. And many of the
interventions that have been implemented
for Zika goes to any screening
of every patient to check if they are
Dengue cases, which is chickungunya, and then Zika. They go into the
algorithms to understand that actually the crisis and
the mortality is for Dengue. Dengue is a real serious public
health problem in Mexico. This also is leading to
different event-based surveillance systems that
very recently has been Zika– also incorporated
in the surveillance during the visit of the pope in
Mexico in the different cities. That was important
because we start assisting the government
when there is linked to the visit of the pope. There were 16 conditions that
were monitored including Zika. And in order to
do that, they need to have the case
definitions– as all of you know that is one of the
critical components– and to the [INAUDIBLE], the
chickungunya with Dengue and Zika. And actually in my
discussions yesterday with our Colombian
counterparts, they indicated that from the
legal perspective all share many of the symptoms. However, they could identify
the Zika by the [INAUDIBLE]– the problem with the skin rashes
that is extremely intensive. And chickungunya is
basically the arthritis and the way people walk. They have a 60% inclination. They differentiate
very well, the clinical suspected cases both in
Colombia and in Mexico. It’s important also for
the sentinel epidemiologist to recognize the
different cities, what is the transmission, and what
is the incubation period, and all the parameters that
are relevant for the response. In Mexico, we have 93
confirmed cases of Zika. Most of them are from
Chiapas and Oaxaca. And all of them
came from Colombia. Colombia is the seed
that entered Mexico. And for the pregnant woman that
has been recognized with Zika, there are eight. And yesterday in my
discussions with the director of epidemiology, they
already have two of them they delivered, and there is
no problem with the children. There is no microcephalia
or any problem with the nervous systems. They intensify– and for us it’s
perhaps very important to see, what is the intensification? This is what is happening also
in the city of Barranquilla. Barranquilla is in the
coast, the Atlantic coast, and is the center– or the epicenter of
the cases of Zika. They are working
very close with us, the Universidad del
Norte is the partner with Hopkins in providing public
health surveillance there. These are the main responses
that are in the country, in Mexico. They change the intensification
of the different surveillance systems. They understood that Mexico is
one of the few countries that have all the
surveillance systems active including
the entomological and the biologic surveillance. And because of that,
they need to provide a lot of the responses from
many other countries in Latin America. They intensify the basic
epidemiological surveillance in all the critical states. They intensify, also, the
entomological surveillance. They focalize particularly
in Chiapas, Oaxaca, Veracruz, the areas that they
have most of the cases. The [INAUDIBLE] that is
of high-end laboratory, they are even sequencing
the genes of the Zika virus. They are already in the banks
at the international level. They recognized that
is the [INAUDIBLE] and they are the
ones that do most of the monitoring
of the biology. Perinatal surveillance and
the neurological surveillance has been developed with
a lot of intensification in specific areas,
not in all the areas, but the areas that are critical. They were very concerned that
the population is not really very aware of the different
protections that need to be done with the vector. They concentrate most
of the interventions against the vector at the
recommendation of the Pan American Health Organization
and the education of the population. But the population
education is not easier. They have been dealing with
Dengue for many, many years. And as you know, the
lack of potable water made it that most of
these population groups– they put water in containers
that become breeding sites for, even, inside the houses. The importance is the response
by Mexico authorities, is that they need to convince
the families and the population that because the transmission
is inside the houses and the breeding
sites are inside, they need to collaborate
in covering the containers and to try to protect themselves
by different of the repellents and the screens in the houses. I also had been in discussion
with the Brazilian authorities, and they are very concerned
about pregnant women. Pregnant women are very
confused by the media. Every single day there
is the intensification of the alerts and
almost the panic. And they try to coordinate
a new public opinion campaign to try to calm down
most of the pregnant women. They incorporate, as
in Mexico and Columbia, the Office of
Gender and Equality. Those are now being part of
the focalized surveillance of maternal perinatal health. In general, we know that
because there is no treatment, most of the interventions
should be against the vector and about the protection
of individuals. Regarding the pregnant women
that are diagnosed with Zika, Mexico was very
concerned if there is the possibility
of microcephalia, but they could not
find any so far. In Columbia, they
are expecting– as Dr. [INAUDIBLE] was
mentioning last week– maybe, they are
waiting for June, July, to see if the ones that were
infected in the first trimester will be the ones that have
been showing the same problems like in Brazil. Brazil is intensifying, also,
some of the surveillance systems for the Olympics. And Mexico decided to
assign two epidemiologists, the [INAUDIBLE] epidemiologists
for the delegation of Mexico that will be in the Olympics. We will be developing a
real time surveillance system for them. And we are moving into
most of the countries to incorporate real
time surveillance systems to monitor what is
happening with these events and problems. With that, I will finalize
my brief presentation for most of your questions. But I want to mention that
for us, in public health, it’s important to understand
when the World Health Organization and the
International Health Regulations of 2005
declare a public health emergency of international
concern, what is the meaning? And so far there
has been only four of these declarations that
mobilized all of the world to address the problem. I hope all of you know which
has been [INAUDIBLE] four declarations because it’s
vital for us in public health to understand when the
international health regulations are
being requested, what happened with all the countries? And there is very interesting– not only the
declaration but also the opportunities for
us in public health to collaborate with these
very important efforts. Thank you very much. JOSH SHARFSTEIN: Thank you
very much, Dr. Castillo. So our next speaker
is Elli [INAUDIBLE]. She is a physician and a faculty
member in International Health. And we thought
that her expertise fit very nicely into this. Because as you go
from the research side into actually implementing
effective programs. You have to be able to think
through all the various steps of what it’s like to take
an idea into the field, and this is an area
of her expertise that she’ll be talking
about with this particular application to Zika. Thank you. ELLI LEONTSINI: Thank you, all. Thanks for coming. I see my students, there
so I’m very pleased. And one second. Bear with me. All right. All right, so today
I chose to take the angle of entomolologic
surveillance, the need for the
entomolologic surveillance and the tailoring of
the community response according to entomolologic
surveillance. So I wanted to start with
some facts about the vector biology of Aedes Aegypti– or Aedes Albopictus,
they’re similar. So this mosquito is silent,
very discreet, is a day biter, and has overwhelming preference
for humans, for human blood– takes multiple blood meals. And so this is
different from anopheles from the malaria vector
that takes one nice sip and then rests on the wall. This one goes around and
picks and takes three or four different blood meals
for one litter of eggs. And so that means it’s in
a highly efficient vector because it can transmit
in very low densities. You don’t need a
lot of Aedes to get an epidemic going, an outbreak. Then where it likes
to hide is in closets, under beds, under
tables where people are and where human smell is. Clothes that are worn once
and put back in the closet are perfect. So it can be present all
over and without people realizing it. So here I want to briefly
go through the lifecycle just because the entomologist
surveillance focuses so much on the lifecycle. So we have the egg, that
when it gets inside water it hatches into larva. Then the larva becomes
pupa for just a day or two. And then from the pupa we have
the adult mosquito emerging. This is the shape of a mosquito. It is Aegypti mosquito eggs. I think you should
take a good look because they are visible by the
naked eye, so you can see them. It’s not dirt what you see. It’s actual eggs. In this slide, I
liked it because it has a nice picture of the pupa
and the larvae in a fish bowl. And this is a nice
one from the CDC where the pupa that was once
down here, now from that pupae, emerges the adult. This is my most important
slide for the day, I think. And if you understand
this, I think you’ll understand vector control
for the rest of your careers, and you will not be confused. So this mosquito,
Aedes mosquito, likes to lay eggs on walls of
containers that contain water– not inside the water directly
but on the walls right above the water’s surface. This is very different
from a anopheles, here, that likes to lay
these eggs, single eggs, but on top of the water surface. They’re floating. And Culex, this is the
pest mosquito, the one that buzzes and bites at night– well, at dusk– and were
most inconvenienced by. This one makes rafts. These are all stacked eggs, and
the raft floats in the water. So what does this tell us
now for our control purposes? If you have standing
water that has no walls you may find a ton
of mosquitoes there, but you won’t find
the Aedes mosquito. So when we say eliminate
stagnant water, what do we mean? It has to have walls. So this is from my
colleague in the DR for some work we were doing. So she’s inspecting
for eggs here along the water surface of
this water storage tank. And here, this is a nice way,
I think, to show the eggs. That’s how they get
deposited in containers with walls, all around
where once the water was. The water probably was
just here in that level. And so they went in
and deposited all around that container. This is what you
have to look for. And so this is just a picture
of habitats of other mosquitoes that could be producing tons
but not the Aedes mosquito because they don’t have walls. Also, the Culex likes very dirty
water, fecally contaminated, and Aedes like these
open, jungle-like puddles. So again, great mosquito
producers but not Aedes. So I want to make a
plea today for the need for entomolologic
surveillance just like we have a huge need for
epidemiologic surveillance and we need EIS officers– that is Entomolologic
Surveillance Officers– that are trained to be
the same detectives just in the same high quality
as the EIS officers. And so I think in the absence
of that kind of expert we tend to readily
transfer information that we have about one mosquito
towards another mosquito and think that all
mosquitoes are the same. Both, I think,
public health people can do that as
well as laypeople. And so it’s important to do
good, careful entomolologic surveillance in the area
that we’re concerned about, and implement recommendations
exactly specifically tailored to our data, and ignore any
other recommendations that come from the media, from
experts, from whatever. You need to know your
surveillance in your area. So a frequent assumption is
that these mosquitoes breed in the garbage, in
containers in the garbage, and that’s not untrue. However, in the majority
of circumstances when we do apply
entomolologic surveillance, we do see otherwise. And Dr. Castillo already
mentioned the water storage problem. In most of the world we have
a big water scarcity problem that generates the
need to store water. And of course, people live with
a vector inside their homes where they store
their own water. This is a picture
from the DR. This is the famous tanque,
tanque de agua. And inside, a lot of
times, you even see a cement lining that makes
it even heavier to tilt, and there is no drainage. And you can’t really
get rid of larvae in this kind of situation. This is the famous pila,
very common in Latin America, where we wash
clothes and dishes. This is the part where you
wash the clothes and dishes and you take water
from here into here. So this is a nice,
great habitat for Aedes. This is from Brazil. In this specific situation,
the cover of this water tank is on top, so that’s safe. As it is like this, it’s safe. But when a hurricane
comes and takes it off, then it’s not safe. This is a very common
water storage container in Southeast Asia, the clay pot. And it’s mostly uncovered, and
you use a smaller container either to drink
or to shower with. This is the traditional bathtub. Who has traveled in
Thailand, Singapore– I mean, Indonesia, Cambodia? Have you seen, can you
identify with this? This is from a travel guide. This is the
traditional bathroom. So this bathtub here is a
water storage tank, really. You don’t get into it to bathe. You use this container to scoop
up water, to flush the toilet, or to take a shower. This has a drainage. It’s very different– sometimes
it has, sometimes it doesn’t. It’s very difficult,
first of all, to see. It’s very dark in there. It’s very difficult to see. The mosquitoes usually are all
along this line, the mosquito eggs. It’s full of larvae
most of the time. It’s very hard to clean. You use the water all the time. You don’t drink that
water so why bother. So it’s a perfect
habitat inside your home. And you’re worrying
about outside, but you have it inside. So this smaller tank
is to flush the toilet. This is to take a shower with. Again, you don’t get in. See how they’re black because
it’s very hard to clean? Same here, it’s
very hard to clean. So this is one type of container
we have to be worried about. The second one is the tires. The tires is a great
way to transport eggs. They provide a haven for Aedes
because it’s dark in here. There’s water if
they are rained on. There is no way to take
the water out of that tire if it’s full of rainwater. No matter how you tilt the
tire and you roll the tire, the water stays in, so it’s
perfect for [INAUDIBLE] positioning in here. So then with the
trade of used tires, they spread the vector
from country to country. I think that’s how
Maryland got infected. This is from Maryland. It’s cleaned up. It’s not a current dump. So when the tires are exposed,
rainwater, of course, gets in, and they become a perfect– we’re going to call
this a factory. Because millions of adults that
are produced from this site then can go to homes. You want to keep
controlling the homes, fine. But if you don’t
control this, you’re going to be getting more
and more infestation. So other important sources
to check and be worried about is la chatarra, a very
famous, perfect word. It’s a mouthful, la chatarra. So this is the scrap
metal, the graveyards. These provide great surfaces
for [INAUDIBLE] position. This is during the
winter with snow. But then when the water
will melt and get filled up, then it’s going to be perfect. You want to ask? AUDIENCE: Does it matter what
the surface is made of or what material that it’s– ELLI LEONTSINI: Yeah, any sort
of plastic, metal, rubber, yeah. And another surface that’s
great is the flower pots in cemeteries. People like to
bring the flowers, but then they leave them there. So then that’s
another factory that keeps seeding onto the
individual households. And you again, control
the households, but then the big site
is there undisturbed. This is from my
colleague in Columbia who sent me this slide, and
this is a new development. And they were supposed to
put roofs in these new homes, but they never did. So this is a full [SPANISH]. A great [SPANISH]. And it’s undisturbed. Gutters are a common thing. In Maryland, I think we
should look for gutters. When they are clogged up
then there’s standing water and walls are there, and
it’s perfect for breeding. And then of course,
the smaller containers that we’re all worried about. And these are when they
are littered all over and there is no waste
collection services, they accumulate rainwater and
then they become habitats. And this particular one– because they are small they’re
not going to produce that many. But because there are many,
many of them collectively, they may be an important site. And then plants,
people love plants, they like to water
their plants so much. And so they are great,
again, for mosquitoes because the plants have sugars. And this is the Bromelia. And inside here there’s
rainwater or watering accumulating here, and
so it’s perfect, again. Each one won’t produce much, but
if you have many in your yard– So then it follows,
after all this, that we have to tailor to those
specific habitats that we find. And so overturning and keeping
upside containers covered. There’s issues with
covering, but I’ll leave it at that for now. I think half covering is worse
than not covering at all. We can get back to it. We have been
involved, in my team, with a method of applying
household bleach on walls of containers right
above the water’s surface to dissolve the eggs. So we’re using bleach as an
ovicide with good results. We’ve used that in Honduras,
El Salvador, the Dominican Republic. This is a sticker on
how to use bleach. You put it on a sponge, and then
you dab it, [INAUDIBLE], you dab it onto the walls. You leave it for 15 minutes. And then the eggs are
dissolved by then, and so you can go ahead
and reuse your container. Tires, very hard
to deal with tires. The correct way is to have them
under a roof, so they are dry. If they’re not under a roof
there are some other things you can cover– you can put lime and so on. So I’ll stop here. I had this in case it
came up, but I won’t. Let me go back. JOSH SHARFSTEIN: Great,
thank you very much. ELLI LEONTSINI: Yeah. JOSH SHARFSTEIN: Wow,
who learned something from that presentation? That was great. I learned, among other
things, that when the mosquitoes are
calling they may be calling from inside the house. That’s a little scary. So we have plenty of
time for discussion. And I want to start by
encouraging questions, just clarifying questions
on the presentations, and then we’ll go to, maybe,
some more in-depth issues. I’ll ask one, but then I’ll turn
it to the audience maybe for– Elli, help me
understand because it was kind of a bleak
picture, all the places, that that can happen. You know, what is it that makes
a successful public health campaign, and can it
really have an impact. I mean, or is it
you do everything you can on the flowerpots,
but it’s something else that’s actually– they all just move over there. I mean is there something about
either the mosquito or examples where you can actually
take your knowledge and apply it to
make a difference? ELLI LEONTSINI: Sure, Josh. So I think a first
public health measure is to control those
factories, the big areas where we have dumps,
cemeteries, so we stop that seeding of the
smaller containers. And then the rest is work
inside the household. For that we need
good communicators with good
relationships, that can form rapport, relationships,
and can go, and show, and tell. And that’s what my work has been
on all these years, developing good counselors. Just like for HIV, you have
counseling and testing, we need counseling and
testing for the household. JOSH SHARFSTEIN: Can you
give an example of a place where that’s been
particularly successful? ELLI LEONTSINI: Oh
yeah, in Honduras we’ve worked for many years. In Colombia, colleagues
of Dr. Castillo’s are working the same. Every vector in Puerto
Rico, in El Salvador– right now Brazil is
mobilizing the army. The army is supposed to go
door to door to do all this, to do the talking. I mean, it’s a new
skill, why not? We will take anyone,
but that’s where we need to put the efforts,
in good relationships. And I think that’s good not just
for Zika, chickungunya, Dengue, whichever you want to take. It’s also good for
the rat problem, for the waste,
the garbage that’s littering our back alleys. Like, we need to communicate
with the household. JOSH SHARFSTEIN: Great. Clarifying questions
people may have. Go ahead. And maybe just
introduce yourself. AUDIENCE: [INAUDIBLE] My idea is about
water sanitation because it seems like if we
didn’t have those standing containers we wouldn’t
have that problem. And I know there are a huge
number of barriers to that, and multiple continents across
the world, millions of people have this problem. But I think it’s an
underlying problem. And I know there
are a lot of people working on water and
sanitation, and technology, and distribution. And I guess I really
don’t understand what the main barriers are. JOSH SHARFSTEIN:
OK, Dr. Castillo. CARLOS CASTILLO-SALGADO:
I think this is very important for
us in public health because [INAUDIBLE] one of
the causes of the causes. Social determinants of
health has been, now, a very important consideration
for any of the responses that are more complicated. Water and sanitation has been
effecting infant mortality but also a lot of
conditions that are dealing with access to water. Like all of these conditions,
chickungunya, Zika, and Dengue, are being affected by that. Then many of the
future interventions should be focusing,
first, in solving that. But also, we need to understand
that our metrics have not been addressing that. What is the percentage of all
the attributable population group that can be ascertained by
water and sanitation and Zika? That’s a very important question
that we need to address. The other consideration that
was in successful stories is Honduras. Tegucigalpa has its main
cemetery in downtown. And it was very
important to have the intervention of the
breeding sites in that cemetery. But it’s difficult
to sustain if there is no solution of the
underlying causes like water and sanitation,
and it’s something that we need to address. Because there are many other
problems, not only these three problems but also
even infant mortality. JOSH SHARFSTEIN: So you have
the economic challenges, but you also have
cultural challenges if you’re doing something
different with cemeteries, for sure. Sure, question. If you could just
wait for the mike. Go ahead. AUDIENCE: I wanted to know
how far from the place where the mosquitoes breed–
how far away do they, like? ELLI LEONTSINI: OK, as
a social entomologist, is there any
entomologists in the room? Do you want to answer? Did you know. AUDIENCE: Well, so I don’t
know the species [INAUDIBLE]. I guess not very far. CARLOS CASTILLO-SALGADO:
So the Aedes mosquitoes travel very short
distances– so less 100 meters from
their breeding site. AUDIENCE: Some
entomological studies have shown that mosquitoes,
under some circumstances, go much farther than
we might expect. And [INAUDIBLE], especially,
are know to go miles. JOSH SHARFSTEIN: Yeah, I think
that might not be the case for [INAUDIBLE], but
if there’s other– ELLI LEONTSINI:
I guess my answer has to be with how much
vector there is around and how much pressure for blood. If you have the family
right there where you are created and were born
and you have so many to bite, you don’t have to go far. CARLOS CASTILLO-SALGADO: Yeah,
I think this is very important. Regarding the anopheles flight,
it’s also a matter of the wind, if that is speeding
even 500 meters. But what is said is important,
most of these problems are urban. And the environment
in the urban they don’t need to travel very far. With anopheles and
malaria it’s different. But in Zika and Dengue,
everything is so close. They don’t need to go farther. JOSH SHARFSTEIN: It
partly depends on whether they have passports. OK, yeah. AUDIENCE: Yeah, on
that topic, I just want to add that sometimes
it’s not just the mosquito, how far they fly, but it’s how
far the humans actually walk when they’re sick. Because they could be bringing
the virus to another place where there are mosquitoes. JOSH SHARFSTEIN: Right. AUDIENCE: Yeah, that
is the other thing. JOSH SHARFSTEIN: Let’s take
this theoretical discussion a little bit to
the practice level here, which would be if we
think that, generally speaking, they don’t go very far. Not to say that there may not
be one that gets on the wind or something like that. To me, that would strike me as
a pretty important public health message and very
motivating for people to take care of their homes. If you think that there
is going to be a breeding ground a mile away, that there’s
nothing you can do at home, it may be less impactful. Is that part of the messaging
that goes on in these areas? CARLOS CASTILLO-SALGADO:
Well, there are two messages. I think that is one. But the other is that because
of the continuous traveling, any infected person that goes
from one country to another will be the seed for
the new transmission. That’s what happened in Mexico. Most of the people that were in
Colombia, they came to Mexico, and that started the problem. We need to understand
the dynamics that this is an urban
problem but also that many of the travelers
that could be infected then could go to other places
and start the new cycle. JOSH SHARFSTEIN: Good, and
either Dr. Brooks or Dr. Leon, what are the messages that
get people to take action on mosquitoes? I mean, if it’s not it will
affect your family’s risk, how do you– what are the
successful campaigns? What are the messages
of those campaigns? How do you motivate people
to take action in that area? ELLI LEONTSINI: Yeah,
so first some knowledge, some key knowledge, is useful. For example, in
communities where people haven’t been focusing
on eggs, by providing them with that knowledge,
is aha moment for them. Oh, I didn’t know. I’ve seen these for so long. I thought they were just dirt. Oh, I didn’t know
they were mosquitoes. Well, let me do
something about it. That is a motivator,
a key knowledge. However, if in the long run if
the methods that we proposed– the methods that we propose
have to be feasible, acceptable, easy to do, incorporated
in a habit, in a routine. So no matter how much
they know, if they have to store their
water they can’t do much. With their smaller containers,
they can do something. So we’ve tried to find methods
that are part of their routine but then use them in a more
interesting, more innovative way. For example, the one that I
showed with the chlorine bleach is a household material
that is commonly found in Latin America. That’s not necessarily
the case all over. But in Latin America
there is a lot of bleach. You know that because you’ve
had your clothes washed there, and you know how they came back. So people love to use
bleach, and we have people that are addicted, in fact. They just dump bleach. So you can moderate that. You can say, you don’t
have to put that much. But it’s something
feasible and acceptable that we’ve found in the
settings that have worked, but I don’t like to generalize
without [INAUDIBLE] research. JOSH SHARFSTEIN: That’s
a very good point. Dr. Brooks, did you? RICHARD BROOKS: Well,
I was just going to say these questions have
definitely fed into, sort of, our discussions about our
plans for vector control, again, acknowledging
that that’s more Maryland Department of
Agriculture than our wheel house. But we’ve talked a lot about
spraying responses, which I think is sort of the
first thing that people here in the United States
think about when they’re talking about trying
to control mosquitoes. I mean, so this is fed into
the conversations around, well, do you just sort of
spray in a general area once we know that
mosquitoes are out? Do you really target your
spraying more to areas around the home where
you know there’s actually been a case of Zika? Do you try to do surveillance
and identify mosquito pools that are infected with
the virus, which is what we do for West Nile virus– but actually functions for
a lot of different reasons differently than how it
works for Zika virus. So those are all things that
are, literally, actively being discussed right now by
MDA and by our experts at the health department
that work on this stuff. So we’re still trying
to figure all this out and trying to determine
what the proper response is. JOSH SHARFSTEIN:
Well, I’m sure it’s going to be a very important
interaction because MDA’s not used to quite thinking through
the algae and mosquitoes. Yeah? RICARDO: back to the
topic that you just– sorry, my name is
Ricardo [? Milan. ?] Talk into the topic that you were
saying about control measures, has anybody thought about
the vision, Zero Initiative? It’s basically saying
that we will never drive, like, mosquito
breeding places to zero. So there will always
be these containers. There will always be litter. And we can reduce it, but
it will never disappear. Human behavior is one of the
hardest things to change. Although I do believe
in educating the public, has anybody [SPANISH]
and the [SPANISH], they’re not going to disappear. Has anybody thought about
making them and giving it to the public, like a cheap
container that is just an easy way to put on top. If you can create something
to cover up the pilas. So that wouldn’t
be changing them. It would be just giving
something that’s already included into their lives. And when these
mistakes happen we just reduce the probability
of mosquitoes. When water accumulates
on top of houses because they didn’t
put a roof up, that will keep on happening in
[SPANISH] with low populations. If we create a type of
brick that can easily drain out or something. This is just me not knowing
anything about architecture or engineering– but just simple things that
when these mistakes happen they won’t help with
mosquito population. Is there any talk about that? JOSH SHARFSTEIN: Sure, so
sort of the general topic of harm reduction
for mosquitoes. ELLI LEONTSINI: it’s me again. JOSH SHARFSTEIN:
Yeah, I think so. ELLI LEONTSINI: first
I’d like to remind us all that eradication
has happened. Fred Soper, a graduate
of our school, did it. The immediate threat
at the time was yellow fever and then Dengue,
or chikungunya, or Zika. And the way it was done
is by doing the hard work, eliminating those big
sites that I mentioned, and then going door to door
and eliminating or controlling, depending, inside the homes. Cuba, Singapore,
are models right now for not having the infestation. They are islands you can say. Maybe it’s easier
for them to do it. They also have very
strong, strict rules and a lot of this hard work. Now definitely, I think if
we don’t want to right away– of course there’s no way we
can discuss about eradication especially right now when
there is an emergency, so yes, definitely– I also work in water
and sanitation. And under that hat, our work
has been to find containers– like the hand-washing
stations that we promote have to be well-covered,
hermetically covered, so they don’t allow
mosquito entry. The drinking water has to be
in narrow mouth containers that are also covered. So we’re trying to limit
the opportunities for Aedes mosquito to get into
these types of containers. For the pilas,
depends on the pilas. Some are just for
longer term storage, so you could cover those. And WHO has tried, actually,
an insecticide impregnated covers for that type. If it’s a frequently used one
then covering is not feasible, but it’s feasible for the
barrels that I showed. There is other? JOSH SHARFSTEIN: Yeah,
I think that’s good. ELLI LEONTSINI: other
things we can do? And then we have of course,
in those bigger cisterns, we have fish, copepods, and
turtles have been used– larvivorous fish, larvivorous
copepods, and turtles. There are issues,
again, with each one, but according to
the situations these are feasible to implement. JOSH SHARFSTEIN: Thank you. Other questions,
we are not entirely required to focus on mosquitoes. So mosquitoes are obviously
very important prevention because we don’t have
a treatment right now. But there are many other public
health practice questions that come up, so I’m hoping
people start thinking of non-mosquito questions. Go ahead. AUDIENCE: OK, so I have
a non-mosquito question. JOSH SHARFSTEIN: OK, excellent. AUDIENCE: So I was wondering
how climate change fits into this because
of water scarcity being such a driver of this
new virus problem that we have and, I’m sure, lots of other
health problems as well. And so I feel like
addressing the containers, especially in
developing nations, is a really huge
task– but maybe in more developed nations,
addressing climate change since we don’t tend to have
those open storage containers in our homes that drive that. I’m just wondering–
your thoughts on that. RICHARD BROOKS: So that was
secretly a mosquito question whether you knew it or not. So yeah, I mean, I don’t
know that any of us actually know specifically how
climate change is necessarily driving Zika in particular. But I mean, you can think
of a lot of ways that it is. I mean, just as one
example, so the range of Aedes Aegypti, which is
the most efficient vector for this current outbreak,
the range for that only extends up to the
southern United States. But as the areas become
warmer, that mosquito may be able to move further
up into the United States into areas including
the Maryland area. We’re right now, albopictus
is the primary mosquito that’s in the Aedes family
that’s around here, and it’s thought to be
a less efficient vector. So that’s just one way
that climate change may affect Zika in particular. JOSH SHARFSTEIN: OK,
a question back there? AUDIENCE: Hi, how are you? My question’s for Dr.
Brook and Dr. Castillo. Dr. Brooks, Perhaps I was
hoping you could maybe tell us a little bit about– well, you seem to have
a lot of questions. So my question is, how
do you find the answers to those questions
and make a decision? What’s the process
for decision making? So for instance, in
emergency management there are systems, the
Incident Command System, ICS, where they have a very
set way of communicating at a certain time of day. And different people
have different positions when there’s not an
emergency, and then when there’s an emergency
they put on a different hat. So in Maryland is that
something that you guys do? And how do those decisions
get communicated? And then my follow up question
for Dr. Castillo is, how do you make sure the surveillance
data that you’re collecting gets to the right people
at the right time? JOSH SHARFSTEIN:
Great questions. RICHARD BROOKS: Yeah,
those are good questions. So the Office of
Preparedness and Readiness is the office that
sort of more directly deals with the kind
of incident command structure on a regular basis
that you’re talking about. Though certainly,
in the situation of having an
emergency, we would fit into that structure, us and
the Infectious Disease Bureau. And so we would partake of
that and use that communication method. And currently, CDC
has their emergency operation center
stood up for Zika and so, are using an
incident command structure for their communications. I would say, just in the
day to day handling of Zika related issues, in my bureau
at the health department, it’s sort of an ad hoc
way of approaching it. So we look to prior
responses and things we learned from prior
experience to inform how we find the answers
to our questions and communicate them out. There are predefined ways of
communicating particularly with the local
health departments, and particularly with
clinicians in the state. So I mentioned that we had
sent out, at least two or three times already, a letter to
every clinician in the state. So those letters are drafted
by us in the department. And then through our office
for preparedness and readiness, they maintain a database
of provider email addresses that gets sort of blasted out
via email to all the providers. And you can limit it to
certain specialties and things like that. And then in terms
of communicating with the local
health departments, there’s a functionality
called a health officer memo. And so again, you
put whatever it is that you want to
communicate into a letter, and then that gets
sent out to each of the different individual
health departments. And when it comes in the form
of a health officer memo, it tends to come with
a certain gravity. And so people pay
attention to it, and they know it’s something
important and something they need to pay attention to. It’s always a little bit
of a fine balance of, you know, what do we actually
send out by clinician letter? What do we send out by HO memo? Because there’s also
message saturation. And if you’re sending things
too often and too frequently, people tend to
start ignoring them, especially when it comes
to the clinician letters. But we do a lot of
things in groups. That’s one of the things that
I really love about DHMH– is that it’s very inclusive. We often meet altogether as a
group, and talk about things, make decisions, try to find
out information together. Even like drafting these
memos and clinician letters, we often do it as a group,
which can be painful at times. Make sure everybody’s
on the same page. JOSH SHARFSTEIN: It’s
a third floor activity, or we go down to
the third floor. I think it’s a great question. As a secretary,
you’re kind of seeing how crazy a particular issue
is at a particular moment. And when it sort of
passes the threshold, I’d activate ICS
and say, we’re going to do this by
incident command, so that we can protect the
people on the third floor who need to actually
figure out what to do. And in the meantime,
we’ll have somebody dealing with the press. We’ll have somebody,
you know– and so it’s a way to get organized, if you
need to, on a particular issue even if it’s just for a few
hours on the height of just complete craziness. But generally we let the chaos
happen on the third floor, and then we get the
results from that process. And so it’s usually very good. Dr. Castillo, do
you want to answer? CARLOS CASTILLO-SALGADO: Yeah,
very interesting and relevant question. Public health surveillance
has been evolving very much since 2005. Before 2005, there was
almost historical data. Now we are moving into
real time surveillance, and that’s a big change. Real time surveillance requires
to understand early warning systems. And early warning systems
require signals, not only diagnosis. And because of that we are now
moving, even in the school, to understand social media. Social media has been very
effective in sending messages in real time. But also, our syndromic
surveillance systems are being modified
by the capacity to create these
alerts thresholds. How to move into the proper
authorities and the community is something that we
need to move faster. The communities are
responding very well. And actually we have now
what we call community-based surveillance systems
that are feeding– many of you [INAUDIBLE] near
you, of feeding the system. And it’s very consistent with
what is happening with CDC. We are much interested
now that the civil society and the community
be fully informed because that’s an area
that, in the past, we didn’t pay full attention. It’s not only the
authorities that obviously had the obligation
to have the response, but also how we involve
the civil society and the community in,
actually, the response. Response is not simple
because many times the people that do the surveillance are not
the effectors of the response. Then they need to go work,
as was said, in teams. And teamwork in
different institutions, sometimes, is complicated. You need, even, a
presidential order for coordination of
different institutions. But I think we need to
remember that surveillance is for action. Anything that is not
going into action should not be monitoring
and surveillance. And we have now
changed, totally, our vision on how to deal with
the public and surveillance. JOSH SHARFSTEIN: So
I’m going to follow up on that part of the
answer, which was great, and say, how many people
agree that the public health surveillance shouldn’t just
be for the public health authorities, that people
generally need to know that? So I want to go into how hard
that can be to implement. I think I would agree
with that principle. So Dr. Brooks is
here from Maryland. And there are cases
that are getting reported of Zika in Maryland. Do you think that
the health department should be telling the public
the number of cases on Zika? How many people think that? Raise your hand. Would it be OK to
do that once a week? Or do you think that
it should– if you think it should be more
frequently than once a week, raise your hand. So it doesn’t have to be
a running ticker of cases. It could be at a
reasonable level. Should it just be
the number, or people think it’s reasonable
for the state– or necessary for the
state to say what the geographic distribution is? How many people think
geographic distribution, you want to know
whether it’s in your– more specific than
county, like city? Or if you think
county is good enough? I mean, you know the health
department knows the house. How many people think that
the house of every Zika case should be– And I was in Costa Rica when
cholera came to Costa Rica in 1992. And they put house of the
first case and all the drainage on the front page of the paper. That’s how I learned
some swear words because the husband of the
first patient was on TV swearing about the decision of the
government to release that. So not the house, how many
people would say the city? OK, and I’m going to go
to some harder– so maybe less than– you
know, some cities are kind of small in Maryland. And these are all
questions that come up. You’ve got to make a policy. And frankly, one
of the best things the public health department can
do is say, here’s our policy. If you hate it, hate the policy. Don’t argue it at
every single time. When we were dealing
with Ebola we said, we wouldn’t confirm that
there was an Ebola suspect case until it was actually
Ebola because we were sick of getting all the calls. And we had an article written
about our press policy. But at least it was about that. [INAUDIBLE] some people
agreed and disagree. How many people think
that the health department should disclose whether a
pregnant woman has Zika? Yeah, raise your hand. Yes? And you’re the reporter. You said there were
50 cases in Maryland. Are any of them pregnant women? Raise your hand, yes. Raise your hand, no. OK, how about, Dr.
Brooks, thoughts on that? You don’t have to– I don’t know if
you have a policy or there’s anything on that. RICHARD BROOKS:
Well yeah, we do. So we are not disclosing whether
people are pregnant, and here’s why. So at the very
beginning of this, we were in contact with one of
the early people being tested. And she was pregnant,
but she hadn’t told a lot of people she was pregnant. But a lot of people knew she
was being tested for Zika. And so if we publicly released
that we had one case of Zika in the State and it
was a pregnant woman. And some of the
people she had told she was being
tested for Zika then found out she was
positive, they would then know she was pregnant. So you would automatically,
in that situation, be releasing to people, that
she didn’t want to know, that she was pregnant. And she may make decisions
around that pregnancy because she’s been
infected with Zika virus to perhaps terminate
the pregnancy. And now you’ve told people that
she’s terminating her pregnancy without her giving you– JOSH SHARFSTEIN: Or
people could start asking her a lot of questions. RICHARD BROOKS: Right, they
put two and two together. JOSH SHARFSTEIN: OK,
anybody change their mind as a result of that explanation? So I’ll tell you that
the test that I applied in that situation is, is it
important for public health for people to know? And if we had a
meningococcal case, we would name the teacher,
the kindergarten class, where she was. You know, that
actually happened, because her students
need to get [INAUDIBLE]. On the other hand,
if it’s something where it’s just sort of
everybody just wants to know, why don’t you tell us? Who is the suspect case of Ebola
in the University of Maryland Medical? You know, we’re not
going to be doing that. There’s absolutely no
public health benefit. So a public health official
has to kind of balance these things, and
you’re probably not going to make
everybody happy on that. OK. CARLOS CASTILLO-SALGADO: I
have a comment about that. We need to recognize
that the best detectives for surveillance
are the media people, DB, and reporters. 60% of all the outbreaks
have been detected by them before us, in public health. And this is very important
why the common centers and the situation rooms
are monitoring the news. Because you can not
believe how insistent I didn’t give a
lot of information for these reporters
when I was [INAUDIBLE]. But they went to my staff,
and they got the information. And that’s very important
for us to understand, that even the WHO
in the countries have the most comprehensive
surveillance system, is in Canada
monitoring the media. It’s very important for us. JOSH SHARFSTEIN: And there’s
even some monitoring Twitter for outbreaks. Yeah? AUDIENCE: I got two questions. JOSH SHARFSTEIN: Oh, OK. AUDIENCE: I’d like to add that
for me, as a social scientist– and I see a few social
scientists in the room if you would like to help me out– I’d like to link such
announcements with behaviors, not just say there
is a Zika case. But so what does this mean for
me that I’m hearing this news? What should I do– and tell what we should do. If there is no action
that follows then we were just creating a– RICHARD BROOKS: Panic. AUDIENCE: –panic, yeah. JOSH SHARFSTEIN:
Great, [INAUDIBLE]. AUDIENCE: Hello,
I’m [INAUDIBLE]. I’m a [INAUDIBLE] student
here at the school. So in the four declarations
of public health emergencies of international concern, they
didn’t happen just like that. They took a while to build
up to being an emergency. And a lot of people
saw them coming. So for example, in
2009 we were seeing that Mexico’s flu
season didn’t end, and we were talking
to CDC flu people. And they were like, well,
it’s probably an abnormal flu season, but nobody really
went and tested for the virus. Then people come
over the border. We found out it’s H1N1. All of a sudden we
have an emergency, and we have a pandemic. With Zika, there was a
huge outbreak of Zika in Gabon in 2007. There was a lot of
French Polynesia. And if you look at some
of those PubMed articles, there’s reporting on this. And there is people in
the field saying, hey, you probably should
look at this– especially with the
one in French Polynesia because these people
are traveling to Brazil, and you have the mosquito there. So there was kind of like
an early warning there but kind of just a mention,
and now we have this emergency. So you know, that’s
two of the four. The other two Ebola, same thing. Months went by
before the emergency was declared for everybody
to be mobilized for that. And the other one is polio. In case, you were wondering
what the four were. So how do we speed
up the process? How do we speed up the process
from when somebody raises a flag to when
major public health authorities like the
World Health Organization, CDC, et cetera,
decide to act on them? CARLOS CASTILLO-SALGADO: I think
it’s a very difficult question in the sense that the
declaration from WHO is not unilateral. It’s part of the discussions. And the authorities,
the WHO, they need to have consultations with
the expert consultation panels, and sometimes
countries are opposing. And the WHO is not an
international agency. It’s actually an
inter-governmental agency. The owners of the organization
are the governments. And if they veto the declaration
then they cannot develop the declaration for the
public health emergency of international concern. The processes that we
need in public health to be more active, and
I think that’s something that they are expecting. And mobilizing the
world for the response requires a lot of consensus. And sometimes we need
to publish that there is some potential correlation. But the actual mobilization
of the globe for the response is not easier, and has not
been done for other conditions. MRSA never had and is a
very important problem. JOSH SHARFSTEIN:
Great, thank you. Does someone have a mike? Yeah, we’re going to go
real fast for the last three questions. Go ahead. AUDIENCE: So, Elli partly
answered this, I think, already, but I wanted to ask
the other two speakers also. Dr. Castillo mentioned
trying to reduce the panic among pregnant women in Mexico. And I’m wondering
what types of messages and what types of activities are
being done there or elsewhere, specifically, for pregnant
women who are certainly panicking about this? CARLOS CASTILLO-SALGADO:
Well, one thing that they are discussing in Brazil is
to discuss with the media because media is part of the
problem with all this panic– and bring in public
figures that the population are accepting as leaders
to send the messages. Many times they use football,
but for pregnant women they need to find a different. In the past, the
president was very good, but now he’s so bad that even
a message from the president will be worse. They need to understand how– first, the press should
suppress so much confusion. And second, find figures
that will send the message. In some countries
they use Telenovelas, and the leaders of Telenovelas
has been very influential. JOSH SHARFSTEIN: Great,
maybe if you both could give your questions
one behind the other, and then we’ll pick answers. Go ahead. AUDIENCE: Well, very
briefly, my name is [? Suraiya ?] Fleischer. I’m a Brazilian
anthropologist, and I’m starting to research Zika. And I have three little,
very short points. One is you mentioned there was
like a flier of suggestions of what should be
done like screen and– CARLOS CASTILLO-SALGADO: Sure. AUDIENCE: And
there was something on the left that was vaccination
against yellow fever. And I would like
to understand how that has to do with Zika
because I never heard of that. That’s the first point. The second point is that
we have been talking a lot about how do we
change individual practices of cleaning our houses
and cleaning our backyards and everything. But in Brazil, from my
point of view in Brazil, we have a major
government problem. That is sanitation, that
is asphalt, and taking care of the public space. So I mean, we have to think
about the individual education part. But I mean, how can
the researchers, and the universities, and
the global institutions help the governments be
responsible for their part? Because for the
Brazilian government, right now, it’s great to talk
about the individual behavior. It’s great. Let’s make responsible
these stupid and, you know, unclean people. That’s the idea, and
that’s very dangerous. And the third thing
is just a suggestion here for the
Bloomberg Center– is that maybe a third seminar
could be the social determinants and Zika. Because we haven’t been talking
a lot about the biology part, and that’s very important– and then epidemiological
part– but maybe the social
determinants, and that would be a suggestion,
just a suggestion. JOSH SHARFSTEIN:
Great, thank you. Thank you. Go ahead. AUDIENCE: Can you please
explain why in Brazil we have more cases of
microcephaly than in Mexico? Especially if you see there is,
maybe, the prevalence in Brazil is higher. Or there’s other causes as– right now, like the
[INAUDIBLE], it’s more for people who had
like a second infection or third infection from the same
family, Flavivirus as Dengue. And if it’s the
latter one, should we be really concerned it’s like a
pandemic or epidemic in cities or countries, which
they don’t Dengue or other viruses
from the same family? JOSH SHARFSTEIN: Just to
respond to that last point at the seminar last
week, obviously, there’s a lot unknown. But the thought is that one
issue is that Zika was first in Brazil, and we
just don’t know how it’s going to play
out in other places that the pregnancies
may be ongoing. And so it may be a little
too early to answer that. But maybe if there’s
something you want to say– and then certainly, the
yellow fever question. CARLOS CASTILLO-SALGADO:
Yes, you already answered. We don’t know. We need to continue
some investigations. Regarding the yellow
fever, actually those are the packages,
countries, they don’t want to do individual
diseases when they are linking yellow fever, they
are putting Dengue, they are putting
chikungunya and Zika. And that’s why they use that. This is what’s prepared, not by
Mexico, but by the World Health Organization and PAHO. And that’s why they
want to maximize that those measures will
have any impact over all the spectrum of conditions
that are based on ideas. And that’s why they put it. RICHARD BROOKS:
So the opportunity to spread public
health messages. And I would put
a plug out there. The similar thing we
have not done for Zika, which we should be
doing, is talking about pregnancy
prevention– which is a huge problem in a
lot of these places– but it’s very challenging,
in particular, in countries that have
large Catholic populations in particular. JOSH SHARFSTEIN: Yeah,
when I was in Columbia, they just had
announced that it was acceptable to get an
abortion in the case of Zika, and that was a big
step for the country. So I think that the point that
was made on social determinants is very important. There is an entire
very important ethical and reproductive
health angle to Zika. This is not going to be– I’m sure, the last
seminar on Zika, but please join me in
thanking our panelists. And it was really an
interesting discussion. For our guests, Dr. Brooks,
we have a T-shirt here even. This is going to have to go
on top of the UNT T-shirt in your class. RICHARD BROOKS: Absolutely. JOSH SHARFSTEIN:
Thank you very much. RICHARD BROOKS: Thanks so much. Yeah, that’s good.

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