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State and local governments will continue to confront a difficult and potentially costly public health challenge this year.
With this year’s mosquito season approaching, the Zika virus continues to pose a serious public health risk—one that threatens to saddle state and local governments in parts of the U.S. with significant costs and other burdens.
Prevention and response efforts around the country last year promise to help guide public health authorities going forward as they combat the mosquito-borne virus. But there are questions about whether adequate federal funding will be available to fuel that fight and whether prevention and response measures could be hindered by a rollback of the Affordable Care Act.
“Zika isn’t gone, it’s sleeping,” cautioned Dr. Aileen Marty, a professor of infectious diseases at the Florida International University Herbert Wertheim College of Medicine. She pointed out that the eggs of mosquitoes that carry Zika are tough enough to survive the cooler winter months and that new cases of the virus continued to get diagnosed in Florida through December.
“Just because something isn’t being reported,” Marty said, “doesn’t mean it isn’t happening.”
Zika is frightening because it can be passed from a pregnant woman to her fetus, potentially causing birth defects and other health problems. Symptoms are typically mild in adults. But scientists are still working to fully understand the disease. Researchers have found the virus can harm the fertility of male mice, raising alarm it could have similar consequences for humans.
The first cases of Zika spread by local mosquitoes in the mainland U.S. were identified last summer in Florida’s Miami-Dade and Broward counties. Since November, authorities have documented at least six locally transmitted cases in the vicinity of Brownsville, Texas.
As of Jan. 18, the U.S. Centers for Disease Control and Prevention reported 4,682 travel-associated cases of Zika in U.S. states and the District of Columbia, along with another 217 locally acquired, mosquito-borne cases. Of the locally acquired cases, 211 were in Florida.
U.S. territories and other countries have been harder hit by the virus. Puerto Rico, for instance, has documented at least 34,358 locally acquired cases, according to the CDC.
The mosquitoes that typically spread Zika are less abundant in the U.S. between December and March and then become more active beginning in April, through the summer months, according to research published online last year through PLOS Currents. The mosquito’s estimated range favors the southern half of the country, but it can potentially survive as far north as New York.
There is currently no proven vaccine available to defend against Zika. Although Marty noted that roughly 40 are currently being tested or have been proposed. In the meantime, across the U.S., state and local agencies are on the front lines in the battle against the virus.
“We have a strong system that we put in place,” said Dr. Umair Shah, the executive director of Harris County Public Health in Texas. But he added: “I don't think any part of the country has ever faced Zika in the way that, eventually, many of us envision that Zika might take hold.”
Fighting Zika in Miami-Dade
Mosquito control efforts in Miami-Dade last summer offer a window into what awaits jurisdictions pitted against a Zika outbreak spread by local mosquitoes.
Paul Mauriello is deputy director of Miami-Dade Solid Waste Management, which oversees mosquito control. He explained that the department did not initially have systems to detect the mosquitoes that commonly carry the Zika virus, a species known as Aedes aegypti.
“I don’t think any of the mosquito districts had any kind of Aedes aegypti surveillance networks in place,” Mauriello said. “At least not down here in Florida.”
“That’s something we had to put together on the fly,” he added. “There was a lot of work revolving around deploying of the traps and servicing the traps. And then getting that data back from the traps, getting basically the mosquitoes back, so that we could have a biologist classify them. We had some of that capability. But not like seven-day-a-week capability.”
Another Zika-related task that confronted officials in Miami-Dade was coming up with a plan for spraying insecticides and larvicides in dense urban areas. Contractors carried out this work using truck-mounted spraying equipment and airplanes. Much of it took place overnight.
“We were using a lot of chemicals,” Mauriello said.
A quirk in the Miami area is a popular type of ornamental plant, bromeliads, which can hold enough water on their leaves to provide mosquitoes a place to breed. “In most of the places where we saw a lot of breeding, the common denominator was bromeliads,” Mauriello said.
Construction sites, he added, were another mosquito breeding hotbed.
At one point, the solid waste department had contracted inspection and abatement crews consisting of 160 workers. These workers were dispatched in two-person teams into neighborhoods to find and eliminate pooling water and other conditions that attract mosquitoes.
The department also collaborated with Florida’s state department of health and the CDC, among other agencies.
Alongside the mosquito control work, health authorities conducted door to door testing in parts of the Miami area seeking to identify people with Zika. Marty was involved in that effort.
She said officials chose to test urine. Although the virus can be detected in other body fluids, like saliva and blood. The turnaround time for test results, Marty said, averaged about four weeks, a potentially long wait, she noted, for a woman who is pregnant and worried about Zika. It’s possible to get results faster, she said, but the number of urine samples made this difficult.
“We really didn’t have all the resources,” Marty said. “That’s why we were begging Congress to stop playing games and get on to funding this.”
Despite the lag time with the federal funding, Marty said that in Miami-Dade: “Ultimately, the response was pretty darn good.”
‘Rob Peter to Pay Paul’
Harris County, Texas includes Houston and has about 4.5 million residents. Figures from Harris County Public Health, updated on Jan. 19, showed 36 reported cases of Zika in the county, none of them believed to be from local mosquitoes.
But when travel-related cases first emerged early last year, Shah’s agency took action. “This was back in January, this was at a time when even the feds and states were really just coming to see Zika,” he said. “We were having to trailblaze a little bit to create our own response.”
The department ended up spending about $1.5 million last year responding to Zika. “Those are dollars that were from our own department’s budget,” Shah said. The expenditure amounts to almost 2 percent of the department’s $80.3 million budget for 2016.
Harris County Public Health also had to shift staff from other priorities to focus on the virus. For instance, a physician hired to concentrate on chronic diseases, such as stroke and diabetes, ended up on the Zika team. “We wound up having to rob Peter to pay Paul,” Shah said.
Guidelines for how federal aid could be provided created roadblocks for the county agency to get its spending reimbursed.
Money flowed to the Houston area through the CDC’s Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement, also called the ELC program. The hitch, according to Shah, is that rules for the program require money to be funneled to the city of Houston, while his department was ineligible for the funding.
“We were able to eventually get some funds from the city for the mosquito control side,” said Shah. This money was $300,000 of the ELC funds and will cover future costs, a spokesperson for the county health department said in an email. But Shah added: “We were never able to, and thus far to date, have not gotten epidemiology dollars.”
James Hodge, Jr., a professor of public health law and ethics at the Arizona State University Sandra Day O'Connor College of Law, cast doubt on whether the money Congress allotted for Zika last year would be sufficient in the face of wider spread, locally transmitted outbreaks.
For Miami-Dade’s solid waste department alone, expenses through last December tied to Zika totalled $17.9 million. The state of Florida had reimbursed the department for $12.3 million of those costs, according Gayle Love, a department spokesperson.
“With the funding we saw available to state and local governments through Congress,” Hodge said, “you couldn’t replicate what they did in Florida across the country if we had New Orleans, Houston, Los Angeles, Phoenix all fall in line with those localized transmissions.”
“What won’t work for the future is thinking that state and locals can pick up that tab,” he added. “It’s too costly.”
Harris County and Miami-Dade are both exploring new techniques and technology to fend off Zika.
Microsoft Corp. last summer selected Harris County Public Health’s Mosquito Control Division to take part in a research project that involves robotic mosquito traps. The traps are designed to ignore insects other than targeted mosquito species. And they’re able to collect a range of data about the surrounding conditions when an insect is caught—like temperature and humidity.
Looking ahead, Shah said the idea is to incorporate aerial drones into mosquito control.
“The vision eventually is that you automate the system,” he said. “You actually find through drone technology where you should place a trap, then you actually go and place the trap through the drone . . . And then the trap itself sends data back and forth to your home base.”
Mauriello said Miami-Dade has been working with the CDC to determine the effectiveness of the In2Care Mosquito Trap. These devices attract the insects and contaminate them with a larvicide powder they then carry to surrounding places, poisoning other mosquitoes before they’re fully developed. “We have several hundred of these out in the field right now,” Mauriello said.
Additionally, he noted that the county planned to test a new inspection and abatement protocol that would reduce door to door outreach in areas where cases of Zika have been confirmed.
Federal aid is not the only area related to Zika where decisions made in Washington, D.C. could have implications for state and local governments. President Trump and Republicans in Congress have vowed to repeal the Affordable Care Act, also known as Obamacare.
Hodge believes eliminating the law, or curtailing the expansion of Medicaid eligibility associated with it, could have drastic effects on how states handle threats like Zika.
On Jan. 17, the nonpartisan Congressional Budget Office issued a report saying the number of uninsured people in the U.S. would go up by 18 million in a year’s time if significant portions of the Affordable Care Act were eliminated and not replaced.
“This will be disastrous when you have an infectious disease outbreak,” Hodge said, as he discussed the prospect of millions of Americans losing their health insurance coverage.
“When you have coverage,” he said, “you go to your pediatrician, to your OB-GYN, you get tested, and we get real results.” Hodge added: “When you don’t have coverage, where exactly do you go? Who exactly has the $500 to pay for that test?”
Bill Lucia is a Senior Reporter for Government Executive's Route Fifty and is based in Washington, D.C.