On February 1, 2016, the World Health Organization declared the spread of the Zika virus an international public health emergency. To date, the virus has infected more than 1 million people in Brazil, spread to an additional 30 countries and overseas territories, and infected about 1,380 people—including 279 pregnant women—in the United States and its territories. As the global community continues to learn more about Zika, ongoing research has confirmed that infection with the virus is cause for grave concern among pregnant women or women who are currently trying to become pregnant.
What we know
The Zika virus is spread primarily through bites from two types of infected mosquitoes: the Aedes aegypti and Aedes albopictus. Evidence also links Zika to sexual transmission from men to their partners. No evidence currently points to sexual transmission from women to their partners. The virus is of special concern for pregnant women because Zika can be transmitted perinatally and lead to severe birth defects.
After a review of existing research, scientists at the Centers for Disease Control and Prevention, or CDC, concluded that there is a direct link between the Zika virus in pregnant women and a congenital brain condition in their fetuses called microcephaly. The World Health Organization describes microcephaly as a neonatal condition that causes infants to be born with small heads. The condition is an indication of slow brain growth, which can cause children to experience developmental disabilities over time. A limited number of studies show that between 1 percent and 30 percent of pregnant women who are infected with Zika have pregnancies with fetal abnormalities. In countries where the virus has a strong presence, such as Brazil, the risk ranges are even higher for pregnant women.
Perinatal infection is most likely in the first or second trimester of pregnancy. A recent case of Zika and perinatal transmission hit very close to home—a pregnant woman from Washington, D.C., tested positive for Zika 10 weeks after returning from a trip to Guatemala. Brain abnormalities were not detected in early ultrasounds of the fetus, but after an abortion at 21 weeks gestation, doctors found severe abnormalities in infected fetal brain tissue. Significantly, there is currently no vaccine to prevent Zika infection.
Zika in the United States and its territories
To date, there have been no locally acquired vector-borne cases of Zika in the continental United States. The majority of the confirmed cases were all acquired through travel to affected countries. However, the U.S. territory Puerto Rico currently has 803 locally transmitted cases and three travel-associated cases—by far the most highly affected location out of all U.S. states and territories. In December 2015, Puerto Rico became the first U.S. territory to report local transmission of the Zika virus. As Puerto Rico continues to grapple with a decade-long recession, half of its residents are living in poverty; most of the poverty stricken are women and children.
The Puerto Rico Department of Health’s plan to address Zika includes increasing lab capacity for testing; enhancing surveillance systems; health messaging and education; distribution of Zika prevention kits; and increasing the availability of contraception, vector control, and targeted outreach to pregnant women through Special Supplemental Nutrition Program for Women, Infants, and Children, or WIC, clinics. As 90 percent of Puerto Rican women received services from WIC clinics in 2015, this strategy should remain a vital component of the health department’s outreach to pregnant women who are at risk for transmission. Women also constitute the majority of Zika cases in Puerto Rico, where the government’s response has been slow to scale due to a lack of resources. Last month, the U.S. Department of Health and Human Services provided $5 million to the territory in order to assist with Zika response efforts.
Looking ahead, the CDC has estimated an uptick in local transmission during summer months due to more-active mosquito populations, particularly in the Southern region of the United States. The Zika virus thrives in warm environments with standing water—which provide a breeding ground for mosquitoes and are characteristic of the South.
The likelihood of Zika transmission could be compounded for low-income people who live in homes without air conditioning or door and window screens or work jobs that require extended periods of time outside. In the South, high rates of poverty and lack of access to health education, jobs, and support services disproportionately plague African Americans and Latinos. It should be no surprise that these communities also disproportionately experience poor health outcomes, including poor maternal health and infant health. Geography aside, economically disadvantaged communities tend to lack access to comprehensive health care and other supports needed to effectively grapple with a public health concern, such as Zika.
Response from the administration and Congress
In February, President Barack Obama called on Congress to approve $1.9 billion in emergency supplemental funds to support the response to the Zika virus in the United States and abroad. Funding would be split between six agencies and departments: the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services, National Institutes of Health, Food and Drug Administration, U.S. Agency for International Development, and U.S. Department of State. The president directed agency teams to track the spread of Zika and to act with vigor in the response. He also met with governors from each state and announced a coalition of experts that—along with federal, state, and local leaders—will work collaboratively to manage the virus and the spread of infected mosquitoes. This year, the CDC will host a summit of key stakeholders and leaders with the goal of ensuring that information and best practices for addressing Zika reach local communities.
Congress has not approved the emergency supplemental funds dedicated to addressing Zika. Rep. Hal Rogers (R-KY), who heads the House Committee on Appropriations, said that he would support the supplemental funding pending the White House’s provision of details regarding the request. However, members of the House of Representatives have introduced their own Zika response spending package, which includes a meager $622 million in funds cut from other programs—far short of the president’s request for new money and hardly enough to fully address Zika transmission. A Zika funding measure has also been introduced in the Senate. It includes $1.1 billion for Zika response efforts—an improvement over the House measure yet still less than the president’s request. Both the House and Senate measures include long-standing abortion restrictions, maintained in federal appropriations bills annually. Abortion funding restrictions have a disproportionate impact on low-income women, making it virtually impossible for them to access the full range of reproductive and maternal health care. Recent developments also point to negotiations that involve a push by congressional leaders to reallocate unspent money from the Ebola fund. Almost $600 million of these funds have already been transferred to fight Zika.
None of these funding measures are enough to implement an adequate response to the Zika virus that involves several government agencies, public health experts, and local stakeholders. In fact, a cost estimate by public health experts from leading research institutions concluded that efforts to address Zika transmission in the United States alone could surpass the $1.9 billion requested by the president. Officials from the Centers for Disease Control and Prevention and the U.S. Department of Health and Human Services have cautioned that failure to allocate funding in a timely manner could stall efforts currently underway, including vaccine research and development; controlling the spread of the A. aegypti and A. albopictus mosquitoes; testing for the virus; and creating targeted prevention and education strategies for pregnant women, women who are trying to become pregnant, and their partners.
The need for a comprehensive approach to reproductive and maternal health
As Zika can be transmitted perinatally and sexually from men to their partners, efforts to address the virus must include a comprehensive approach to meeting the sexual, reproductive, and maternal health needs of women. Women living in areas where there is an increased risk for infection must be provided with counseling and access to the contraceptive methods of their choice. Both male and female condoms must also be made available. As stated previously, Zika transmission in pregnant women is cause for grave concern.
When a pregnant woman tests positive for Zika, the birth defects associated with the virus may not be detectable in the fetus until after 20 weeks gestation. In light of this concern, women who have tested positive for the virus and choose to carry their pregnancies to term must have access to comprehensive prenatal and postnatal care. Counseling, education, pediatric care, and social supports must also be provided for women who give birth to infants with microcephaly. In the event that a woman makes the difficult decision to terminate her pregnancy, safe abortion care should be made available to her. Many of the states included in the CDC estimation for the Zika uptick also ban safe abortion after the first trimester of pregnancy. Some exceptions for fetal anomalies are attached to the bans in Georgia, Louisiana, Mississippi, West Virginia, and Texas.
Local health systems that are affected by Zika—particularly in the American South and U.S. territories—may operate under resource constraints in the face of critical public health concerns. Previous analysis shows that Southern states have high concentrations of underserved communities due to an inadequate number of health care providers, hospitals, and clinics. The South has a poor track record in meeting the health needs of high-risk communities, particularly in the areas of reproductive and maternal health. These systems must be enhanced in times of need in order to ensure access to timely, quality care. Low-income women may need targeted outreach for comprehensive health services and education, similar to the Puerto Rico Department of Health’s strategy for reaching pregnant women in WIC clinics. Information disseminated through local channels should include content related to all modes of transmission, including through mosquito bites, as well as perinatal and sexual transmission.
Conclusion
It is imperative that Congress act swiftly to approve the $1.9 billion in emergency supplemental funds requested by President Obama in support of the U.S. response to the Zika virus. Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, has stated that additional funding from Congress is crucial to effectively fight Zika transmission. The White House has already put an initial plan in place that will engage key stakeholders across the public sector, states, and U.S. territories. However, policymakers will not be able to effectively usher this plan along without adequate funding.
Now is certainly not the time for political wrangling, as the lives and health of the nation’s most vulnerable communities are at stake. And while relevant agencies and local public health systems are setting up plans to combat Zika, efforts are currently at a halt due to lack of resources. The cost of waiting greatly outweighs the benefit of directly addressing Zika. Policymakers must take proactive measures to stop transmission in its tracks and ensure that women and children, the populations most susceptible to grave outcomes, have vital supports. Essential to these supports is a comprehensive approach to sexual, reproductive, and maternal health that includes the full range of services to ensure that all women have access to quality care that addresses their unique needs. Counseling, contraception, prenatal and postnatal care, social support services, and safe abortion if a woman so chooses must all be included in the full constellation of Zika-related care.
Jamila K. Taylor is a Senior Fellow at the Center for American Progress.