Author: Leah Goodman
Abstract
Zika is a virus that infected over 35,400 individuals in Puerto Rico in just a 16-month period, making up 85% of all cases reported in the U.S. and its territories. Although Zika’s natural reservoir is non-human primates, the primary transmission at this time was through mosquitos. This regional public health emergency posed a significant threat to pregnant women specifically due to the risk of fetal birth defects, such as microcephaly.
The outbreak exposed the questionable efficacy of public health policies that primarily target the individual while failing to address the systemic and structural issues of the geographic area. Policy recommendations from the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) focused primarily on individual prevention methods such as mosquito avoidance and safe sex practices; the main focus of surveillance was pregnant women and couples looking to conceive. Policy should have also concentrated on encouraging public health leaders of Puerto Rico to address the political, social, and economic barriers to healthcare access. The territory was under-resourced due to the Congressional spending cap for health services on the island, posing a humanitarian crisis as they tried to combat the spread of Zika. Mitigation measures should have incorporated improving access to healthcare, amplifying communication of risk, strengthening trust with health authorities, and utilizing education. Failing to properly focus intervention methods impeded the overall response. Since the end of 2017, there has been an extreme drop in confirmed cases of Zika in Puerto Rico; this is mainly due to the development of herd immunity. However, Hurricane Maria in September of 2017 halted the majority of surveillance.
Background
Zika is an arthropod-borne flavivirus: arthropod-borne meaning the vector is insects, and flavivirus describing the genus of the positive-stranded RNA virus. In this case, the primary vector is an Aedes mosquito, similar to the Dengue and Chikungunya viruses. The natural reservoir however, is non-human primates. Symptoms of Zika in humans are mild and relatively short-lived, consisting of fever, rash, headaches, joint pain, and conjunctivitis; however, 80% of cases are asymptomatic. While mortality is rare, infection can result in severe neurological complications and adverse fetal outcomes. Specifically, Zika can cause Guillain-Barré syndrome, a rare autoimmune disease that can lead to paralysis, and microcephaly, a birth defect in newborns that is characterized by an abnormally small head. The primary modes of viral transmission consist of a bite from a mosquito and sexual transmission. There is also a chance of vertical transmission when a mother becomes infected during pregnancy and transmits the virus to her fetus. It has been suggested that Zika can also be spread through breast milk and blood transfusions though there have been no confirmed cases from these modes. Mortality has occurred in cases where individuals had an underlying condition such as sickle cell, or death has resulted from the paralysis associated with Guillain-Barré syndrome. There is currently no vaccine.
The first case of Zika virus was reported in a rhesus macaque monkey living in the Zika Forest of Uganda in 1947. The symptoms in non-human primates are mild, and mosquitos can only become infected during a short infectious period. The first human case did not occur until 1960. In the late 1970s, a study was conducted in Indonesia in which additional hosts were identified such as horses, cows, water buffalo, ducks, and bats; however, there is no evidence that transmission to humans from these hosts is possible. Once Zika arrived in Brazil in 2015, the disease spread rampantly, making its way to Puerto Rico by the end of the year. In August of 2016, the Obama administration declared a Public Health Emergency (PHE). Based on the International Health Regulations Emergency Committee recommendation and increasing cases of neonatal and neurological disorders, the WHO declared Zika virus a Public Health Emergency of International Concern (PHEIC) on February 1, 2016.
Relevant Policy
Various policy recommendations were made by the CDC and the WHO in the effort to control the spread of Zika virus. Individual protection from mosquito bites was the primary recommendation. These recommendations consisted of vector control, focusing on source eliminations such as removing any standing water around the residence, wearing long clothing, using Environmental Protection Agency (EPA)-registered insect repellent, repairing all screens, and using mosquito nets while sleeping. As Zika can be spread through sexual intercourse, safe sex practices and abstinence were recommended. Educating oneself about the risks associated with sexual transmission of Zika was also encouraged. Due to the significant threat to pregnant women, authorities recommended postponing planned pregnancies. It was also stated that pregnant women should not travel to areas where Zika outbreaks were ongoing.
During the severe uptick in Zika cases, it became apparent that the disease had the potential for further international spread, aided by rising temperature associated with climate
change. The WHO enacted its Emergency Operations incident management system to coordinate an international response. This system, called The Strategic Response Framework and Joint Operations Plan, is a comprehensive policy that was implemented in response to the outbreak in February of 2016. The plan aimed to provide support to the affected areas and build capacity to prevent and control further outbreaks through facilitating research to increase understanding of this virus and its outcomes. There was an emphasis on helping affected areas, like Puerto Rico, enhance their surveillance efforts to combat the spread and gather data linking cases to disorders. The Plan stated the WHO would need $56 million for implementation.
The Gaps
Interviews were conducted with the island's locals during the outbreak in which they discussed the challenges associated with following policy recommendations. They believed there were simply more pressing matters than the Zika virus; the low fatality rate and lack of proper education and communication surrounding the virus emboldened this mindset. Puerto Rico was simultaneously faced with high crime rates, political instability, a decade-long recession followed by a debt crisis, almost half the population living below the poverty line, and unemployment rates double that of the continental United States. Additionally, citizens of Puerto Rico expressed distrust in health officials, specifically the CDC, after their initial proposal to aerially spray insecticide to combat the virus. The mayor of San Juan referred to the recommendation as environmental terror, and the Governor eventually blocked the effort completely. Attempts to stop the spread in Puerto Rico were impeded by mistrust in health officials and the territory's socioeconomic barriers. The policies set forth overlooked these obstacles and placed responsibility too heavily on the individual. For example, policies focused on individual vector control while open landfills were identified as prevalent breeding grounds for mosquitoes. Yet, there was little effort by the government or the citizens to control these areas.
In Puerto Rico, 49% of the population depends on Medicaid for their healthcare, more than double the rate of the rest of the United States. Unlike the 50 states, annual federal funding for Puerto Rico’s Medicaid program is subject to a statutory cap. This means once federal funds for healthcare are exhausted, the island no longer receives financial support for that fiscal year, which leaves countless individuals without access to healthcare for extended periods of time. Due to the cap, residents of Puerto Rico are less likely to seek routine care during the year. As a territory, Puerto Rico faces unequal access to Medicaid funding and therefore, is left more vulnerable to an infectious disease outbreak. According to the Government Accounting Office, if Puerto Rico had been a state in 2011, federal spending would have ranged from $1.1 billion to $2.1 billion; in 2017, the island’s Medicaid funding was capped at $347 million. Although the territory is treated as a state in many other policy arenas, they are treated worse than the poorest state in the U.S. in terms of access to healthcare.
Recommendations
When creating policy around an outbreak, it is important to understand and incorporate the social, economic, and political climate of the target region or population. Encouraging public health leaders in Puerto Rico and the U.S. to address the structural barriers to prevention, rather than placing responsibilities primarily on the individual, will improve the effectiveness of policy and response. For example, if the citizens of Puerto Rico are more concerned with the rising unemployment and crime rates, policy recommendations for Zika prevention will not be prioritized, especially when a large percentage of cases are asymptomatic. The territory needs affordable, accessible reproductive and preventative healthcare services that offer multiple forms of contraception, prenatal diagnostics, and safer abortion options.
The efforts to stop the spread of Zika were hampered by mistrust. Education is one of the greatest tools in combating an outbreak when integrated with trust in health officials. Zika differed from the other mosquito-borne diseases that had targeted Puerto Rico in the past; this disease had the ability to be transmitted sexually, and many were unaware of the adverse consequences associated with pregnancy during infection; there was also an
asymptomatic case rate of 80%. Investments in early sex education that incorporate the risk of Zika transmission should be implemented in schools. This can be achieved through the involvement of nonprofits to integrate interventions at the educational and community level. As Zika is sexually transmitted, a confidential hotline for sensitive information would prove useful for those seeking advice and information regarding the disease. Training of service providers on updating contraceptive methods, such as IUDs and implants, would help prevent unplanned pregnancies as well as the transmission of Zika from mother to fetus, thus preventing any adverse fetal outcomes. It is pertinent that all clinical staff, case managers, and counselors are trained on how to effectively communicate information regarding Zika and the risks associated with sexual transmission. Public policy regarding reproductive health and access to services needs to emphasize the importance of preventative care and routine healthcare visits. Political will is necessary to maintain public information campaigns to educate and motivate the population of Puerto Rico to take Zika virus seriously.
Legislative action is long overdue to reform Puerto Rico’s Medicaid program structure upon which 1.4 million citizens are dependent. The Zika outbreak exemplified how under-resourced Puerto Rico was due to the Congressional spending cap for health services. The Governor of Puerto Rico must push for equal treatment with the states in terms of federal healthcare funding. The health needs of the territory are not being met by the annual spending allotment, and reassessments are failing to keep up with necessary Medicaid costs. Reform is also necessary to increase the coverage of Puerto Rico’s Medicaid program, which is unequal to the coverage offered in the states. Coverage must be expanded to cover expenditures such as prescription drugs, nonemergency medical transportation, home-health care, nurse practitioner services, and nurse-midwife services. Improvements in provider reimbursement are also vital to the survival of Puerto Rico’s healthcare system. Currently, reimbursement is extremely low, placing financial stress on healthcare workers and causing an increase in migration out of the territory; consequently, there is a shortage of providers in Puerto Rico. As of 2019, 72 out of 78 municipalities have been designated as medically underserved areas.
Conclusion
Failing to properly focus intervention methods impeded the overall response to Zika in Puerto Rico. Additionally, failure to effectively communicate risk combined with a broken healthcare system resulted in 5 deaths, 122 cases of microcephaly, and 56 cases of Guillain-Barré Syndrome. The policy recommendations by the CDC and WHO were implemented correctly; however, if citizens are not properly informed on risk, the policies will be ineffective, especially in areas with such prominent systematic barriers. Although Zika is no longer considered a risk to the area, there will continue to be mosquito-borne illnesses that plague Puerto Rico in the future, and lessons learned from Zika will be an advantageous tool. The island must continue to invest in surveillance. Hurricane Maria hit Puerto Rico September of 2017 and due to limited resources, all government surveillance of Zika was halted in order to focus their efforts on responding to the hurricane. There is a risk of cases going undetected if the resources to surveil are nonexistent. Puerto Rico requires long-term Zika prevention measures to ensure health security of its citizens.
This article was prepared by the author in their personal capacity. The opinions expressed in this article are the author's own and do not reflect the view of their place of employment.
Comments