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S. HRG. 114–743 

ZIKA IN THE WESTERN HEMISPHERE: 

RISKS AND RESPONSE 

HEARING 

BEFORE THE

SUBCOMMITTEE ON WESTERN 

HEMISPHERE, TRANSNATIONAL CRIME, 

DEMOCRACY, CIVILIAN SECURITY, HUMAN 

RIGHTS, AND GLOBAL WOMEN’S ISSUES 

COMMITTEE ON FOREIGN RELATIONS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

JULY 13, 2016 

Printed for the use of the Committee on Foreign Relations 

( 

Available via the World Wide Web: 

http://www.fdsys.gpo.gov 


FOREI-42327 with DISTILLER
COMMITTEE ON FOREIGN RELATIONS

BOB CORKER, Tennessee, Chairman

JAMES E. RISCH, Idaho 

MARCO RUBIO, Florida 

RON JOHNSON, Wisconsin 

JEFF FLAKE, Arizona 

CORY GARDNER, Colorado 

DAVID PERDUE, Georgia 

JOHNNY ISAKSON, Georgia 

RAND PAUL, Kentucky 

JOHN BARRASSO, Wyoming 

BENJAMIN L. CARDIN, Maryland 

BARBARA BOXER, California 

ROBERT MENENDEZ, New Jersey 

JEANNE SHAHEEN, New Hampshire 

CHRISTOPHER A. COONS, Delaware 

TOM UDALL, New Mexico 

CHRISTOPHER MURPHY, Connecticut 

TIM KAINE, Virginia 

EDWARD J. MARKEY, Massachusetts 

TODD WOMACK, Staff Director

JESSICA LEWIS, Democratic Staff Director

JOHN DUTTON, Chief Clerk

SUBCOMMITTEE ON WESTERN HEMISPHERE, TRANSNATIONAL 

CRIME, CIVILIAN SECURITY, DEMOCRACY, 

HUMAN RIGHTS, AND GLOBAL WOMEN’S ISSUES 

MARCO RUBIO, Florida, Chairman

JEFF FLAKE, Arizona 

CORY GARDNER, Colorado 

DAVID PERDUE, Georgia 

JOHNNY ISAKSON, Georgia 

BARBARA BOXER, California 

TOM UDALL, New Mexico 

TIM KAINE, Virginia 

EDWARD J. MARKEY, Massachusetts 

(II)


FOREI-42327 with DISTILLER
C O N T E N T S 

Page 

Rubio, Hon. Marco, U.S. Senator From Florida .................................................... 1 

Boxer, Hon. Barbara, U.S. Senator From California ............................................ 4 

Garber, Hon. Judith G., Acting Assistant Secretary, Bureau of Oceans and 

International Environmental and Scientific Affairs, U.S. Department of 

State, Washington, DC ........................................................................................ 6 

Prepared statement .......................................................................................... 7 

Frieden, Dr. Tom, Director, Centers For Disease Control And Prevention, 

Atlanta, Georgia ................................................................................................... 9 

Prepared statement .......................................................................................... 11 

Koek, Irene, Acting Deputy Assistant Administrator, U.S. Agency for International Development, Washington, DC ............................................................ 15 

Prepared statement .......................................................................................... 16 

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

ZIKA VIRUS EXPLAINED, Emerging Pathogens Institute, University of Florida, 

February 19, 2016. ............................................................................................... 42 

Statement Submitted by the Center for Vaccines and Immunology at the 

University of Georgia ........................................................................................... 79 

(III)


FOREI-42327 with DISTILLER

FOREI-42327 with DISTILLER
(1) 

ZIKA IN THE WESTERN HEMISPHERE: 

RISKS AND RESPONSE 

WEDNESDAY, July 13, 2016 

U.S. SENATE, 

SUBCOMMITTEE ON WESTERN HEMISPHERE, 

TRANSNATIONAL CRIME, CIVILIAN SECURITY, DEMOCRACY, 

HUMAN RIGHTS, AND GLOBAL WOMEN’S ISSUES, 

COMMITTEE ON FOREIGN RELATIONS, 

Washington, DC. 

The subcommittee met, pursuant to notice, at 2:54 p.m., in Room 

SD–419, Dirksen Senate Office Building, Hon. Marco Rubio, chairman of the subcommittee, presiding. 

Present: Senators Rubio [presiding], Gardner, Isakson, Boxer, 

Kaine, Udall, and Markey. 

OPENING STATEMENT OF HON. MARCO RUBIO, 

U.S. SENATOR FROM FLORIDA 

Senator RUBIO. Thank you. Good afternoon. And today’s hearing 

on the Subcommittee on Western Hemisphere, Transnational 

Crime, Civilian Security, Democracy, Human Rights, and Global 

Women’s Issues will come to order. And I thank all of you for being 

here today. 

The title of this hearing is Zika in the Western Hemisphere: 

Risks and Responses. We will have three witnesses: Ms. Judith 

Garber, the Acting Assistant Secretary, Bureau of Oceans and 

International Environmental and Scientific Affairs at the U.S. Department of State; Dr. Tom Frieden, Director of the Centers for 

Disease Control and Prevention; and Ms. Irene Koek, the Acting 

Deputy Assistant Administrator of the U.S. Agency for International Development. 

We thank you all for being here today. We apologize for starting 

late. We—the Senate gods decided to schedule a vote right as the 

time we were supposed to begin. But we appreciate your time and 

your dedication. 

And I would also like to thank all of those who worked alongside 

my staff to make this hearing possible. 

Today, we face an issue that is already affecting many countries 

in our hemisphere, including our own. It is not partisan in nature. 

The growing threat of the Zika virus as a full-blown public-health 

crisis in the United States is a clear call to action. 

Just look that statistics. As of July, 65 countries and territories 

have reported evidence of vector-borne Zika virus transmission. 

What is even more troubling is the fact that four countries are clasVerDate Mar 15 2010 11:01 Mar 01, 2018 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 S:\FULL COMMITTEE\HEARING FILES\2016 HEARINGS -- WORKING\071316 27-830\27-8

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sified as having possible endemic transmission or have reported 

evidence of local vector-borne Zika infections in 2016. 

As much as Zika remains a threat on the international stage, it 

also poses a real and timely threat to our country. That means, in 

these countries, a disease that has already spread rapidly and 

made its way into the population. We are seeing this, as well, is 

the island of Puerto Rico. And Puerto Ricans, as you all are well 

aware, are American citizens, and Puerto Rico is an American territory. According to the statistics from the World Health Organization, the United States is one of 11 countries with evidence of person-to-person transmission of the Zika virus. That means that our 

neighbors, our friends, our families are already at risk, even without mosquito-borne transmission, though that is likely coming, as 

well. 

As the threat of the virus continues to grow here, I will continue 

to state the importance of moving quickly in response. I strongly 

believe that inaction on Zika is simply inexcusable, and I am optimistic that, after reviewing the facts and hearing from the experts 

here today, it will reinforce this fact and the fact that something 

needs to happen quickly. It has taken far too long already. The effects of the Zika virus are alarming, to say the least. Pregnant 

women or women who have become pregnant have contracted the 

virus and are at risk of having babies with microcephaly. 

For those not familiar with microcephaly, it is a birth defect that 

causes severe neurological abnormalities, which can include small, 

deformed head. This has a permanent and severely detrimental impact on the development of the baby’s neurological system and 

quality of life. Those born with microcephaly may experience seizures, intellectual disabilities, hearing and vision loss, as well as 

a number of other horrific symptoms. 

It is our responsibility to the American people to take action 

when public health is in jeopardy. Although the mainland of the 

United States may not be worried about Zika right now, there are 

already 1,133 cases, and they are found in 45 out of 50 States. Just 

last week, the CDC reported that they are currently monitoring, in 

the United States, 320 cases of Zika in pregnant women. 

The CDC Director, who joins us here today, called Zika a ‘‘silent 

epidemic.’’ As of now, many predicted what would happen in the 

summer. The spread of the virus is now accelerating. The Friday 

before last, Federal health officials confirmed the largest number 

of new Zika infections in a single day in the State of Florida, with 

10 new cases. That was a short-lived record. It was broken last 

Wednesday, when Florida confirmed 11 new Zika infections, that 

time in six counties, including Lake County, Florida, which had 

never had a case before. That record was broken again on Monday 

of this week, when 13 new infections were reported. And so, you 

get the idea. The problem is not—is only going to continue to accelerate. 

This is not the first time I have spoken on the growing threat 

of Zika. In late January of this year, as I was somewhere outside 

of Florida, I saw a headline in the New York Times that stopped 

me in my tracks. It said, ‘‘Report of Zika-Linked Birth Defects Rise 

in Brazil.’’ The article went on to say, ‘‘The health authorities in 

Brazil said, Wednesday, that reported cases of microcephaly, a rare 


FOREI-42327 with DISTILLER
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condition in which infants are born with abnormally small heads, 

had climbed to 4,180 cases since October, a 7-percent increase from 

the previous tally last week.’’ And it stopped me in my tracks, for 

a number of reasons. First was the staggering number and the 

breakneck speed with which the disease was spreading over just 

the course of a week. But it also made me pause because, for those 

of us who live in South Florida and travel through Miami International Airport, we know very well what happens in—we know 

very well that what happens in Brazil impacts us in the United 

States, especially in Florida. 

A couple of days after that, I reached out to the U.S. Customs 

and Border Protection to express my concerns, and asked what 

they were doing, or could do, about this, given Miami International 

Airport’s standing as the Gateway to the Americas, with more 

flights and passengers going to and from Brazil than any other 

U.S. airport. 

Here on the Senate floor and back home in my State, I have 

called for action from my colleagues. I urged support for fully funding the President’s funding request to deal with this virus. I have 

supported every single Zika proposal that has come before the Senate. Every single one. But nothing has gotten done. The problem 

is only getting worse. 

It is our duty to act now, while we can still get ahead of this disease and before it is simply too late. I believe the Congress has a 

constitutional responsibility and a moral obligation to confront the 

Zika virus. It is my hope that today’s hearing will further call attention to the seriousness of this situation and what more we can 

do in the western hemisphere to help fight it. This challenge we 

face is emblematic of how interconnected we are as a country with 

our neighbors. In this global economy, public health crisis do not 

respect international borders. The negative impacts of these problems, from the economy to political instability, can easily impact us 

here at home. 

The links between our country, especially Florida, and other nations of the western hemisphere are obvious. I have already covered Brazil, but, for example, the first baby born in Florida with 

Zika-related microcephaly was a mother who came from Haiti. Last 

month, Time reported that 12,000 pregnant Colombia women have 

Zika. The Zika virus is already a U.S. public health emergency. 

The problem is even worse in Latin America. It is only growing by 

the day. And the links between our nations make this a hemispheric public health crisis, where, once again, American ingenuity 

and innovation in the medical sciences must lead the way if we are 

to help save lives, including countless unborn children. 

We must begin to meet the Zika virus with a sense of urgency 

that we have not seen up to now. Listen to the experts from 

around. It is time to act—it is time to enact serious solutions. 

I am proud to stand as an advocate for any legislation that would 

provide funding to combat Zika as soon as possible. And we cannot 

rest until we have taken action in order to ensure the safety and 

health of the American public. 

Thank you. 

With that, I recognize our ranking member, Senator Boxer. 


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STATEMENT OF HON. BARBARA BOXER, 

U.S. SENATOR FROM CALIFORNIA 

Senator BOXER. Thank you so much, Mr. Chairman, for this 

hearing. 

Thank you, to our witnesses, our guests. 

Few issues pose as immediate a threat to the health of Americans as the Zika virus. The virus has caused severe birth defects 

in thousands of newborns. These birth defects include brain damage, blindness. They are devastating to mothers, to families, to 

communities. In some cases, we have seen the premature death of 

children. 

The Zika virus has caused a rare disorder in adults in which the 

body attacks its own nervous system, causing paralysis. The Zika 

virus is also linked with another autoimmune disorder that resembles multiple sclerosis, which causes swelling in the brain and the 

spinal cord. We only have to listen to public health experts to get 

a clear sense of the virus’s danger. 

The World Health Organization has said that the Zika virus is, 

‘‘spreading explosively.’’ in the Americas and threatens to overwhelm almost every country in the western hemisphere. The Center for Disease Control and Prevention has said the virus is, ‘‘scarier than we originally thought.’’ 

The Zika virus is already here in the continental United States. 

Over 1,000 people have already contracted the virus through travel 

or sexual conduct. And as the disease travels northward from that 

Latin America and the Caribbean, up to 30 States are in danger 

of local outbreaks from mosquitos carrying the virus. Thirty States. 

This includes California and the Chairman’s home State of Florida. 

In short, we need to act now. It is a real threat, and it is dangerous. 

Now, here is the great news. The great news is, the Senate had 

bipartisan legislation, which is what you have when you have an 

outbreak like this. It was proposed by Senators Blunt and Murray. 

It provided the administration with less than they wanted, but, 

nonetheless, $1.1 billion. When the President requested $1.9 billion, the two Senators negotiated, and the best they could come up 

with was $1.1 billion. But the compromise would have gone a long 

way without having poison pills and ridiculous riders that are dangerous to the American people included in the legislation. What 

happened to that bill, that wonderful bill that my Chairman voted 

for, that I voted for, that we all voted for? It disappeared down the 

black hole of partisanship. 

The Republicans in the House had a conference, and they did not 

allow any Democrats into that conference. Not Senator Mikulski, a 

woman who we revere around here on both sides. Not Senator 

Murray, who has worked across the aisle on so many issues. No. 

They left them out. And you know what they came out with? A bill 

that actually restricts funding for birth control in the United States 

and in Puerto Rico, even though they know—they know that Zika 

can be transmitted sexually, and birth control should not be controversial, and it is part of the first line of defense. There is no 

room for politics in this. 

Listen. The report also overrides the Clean Water Act. And I 

know about this, because I am the ranking member on the EnviVerDate Mar 15 2010 11:01 Mar 01, 2018 Jkt 000000 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 S:\FULL COMMITTEE\HEARING FILES\2016 HEARINGS -- WORKING\071316 27-830\27-8

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ronment and Public Works Committee, and was Chairman of that 

committee. A landmark law that was passed by Republicans and 

Democrats. It overrides it. It allows the uncontrolled pesticide 

spraying near water supplies that we drink out of and our children 

swim in. Pesticides that could poison our people. 

Now, you may say, ‘‘This is an emergency. Should we not be able 

to spray?’’ The answer is, under the Clean Water Act, you can. You 

do not even need to get a permit. The Clean Water Act understands this. It is a brilliant piece of legislation. And it says, ‘‘In an 

emergency, you do not need to get a permit. Go ahead and spray. 

Spray the amounts necessary off the approved list, and just notify 

the EPA—just notify the EPA.’’ —Well, that was not good enough 

for my friends over there. They completely take away that whole 

section of the Clean Water Act. And that means that there is no 

more right to know if somebody goes next to your house and sprays 

some horrible pesticide that causes cancer, that is not on the approved list. You have no way of knowing that has happened. And 

the Clean Water Act is smart. Once the emergency is over, they sit 

down with the local agency, and they figure out a way to maintain 

it. 

Here we have a circumstance where the House Republicans, 

without any consultation with anybody, completely eviscerate the 

Clean Water Act. so you may not get the Zika, but your kid could 

get cancer from swimming in water that is laden with a pesticide 

that is very harmful. Where is that sensible? You cannot just say— 

I am speaking for myself—I cannot say I am going to vote for any 

bill, because what if the bill does as much harm as it does good? 

We are legislators. We have to be careful what we do, what we vote 

for. 

They took out the possibility for nonprofits to do birth control, 

which is the first line of defense against this Zika. They completely 

eviscerated the Clean Water Act, which makes it dangerous for our 

people. They even put something in there about the Confederate 

flag, which my colleague Senator Kaine understands, was explaining to me. He can do a better job of explaining it. But essentially, 

it overrode another bill, where we said you cannot fly the flag in 

veteran cemeteries. They did away with it. In the Zika bill. 

It is discouraging. And I call on all of us who voted for that bipartisan bill—and it is all of us here, as—far as I know—bring 

back that bill, keep out the bad stuff. Let us get it done. It is bad 

enough they cut funding for Ebola. That thing could rise up again. 

That is horrible. But these things are added, if you will, insults to 

the no—to the American people thinking that we are doing something good, when we are doing some bad things, as well. 

I just wanted to say quickly, in closing, I am so disgusted with 

the situation, as we all are, every one of us—we do not know how 

we got here. It just got here. So I am hoping we can do something 

different in the future, Mr. Chairman. And I have written legislation. It would create a $3 billion emergency public-health fund, 

kind of like FEMA—kind of like FEMA—where it would be within 

the Department of HHS and allow the CDC and HHS to use those 

funds to address global health threats. And it would allow them to 

go in, they would notify Congress. We could overrule them if we did 


FOREI-42327 with DISTILLER
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not like it. But we would not put politics in the middle of this 

thing. 

I am, you could see, a little worked up. And I apologize. Maybe 

I am a little too worked up. But I share my friend the Chairman’s 

view on this Zika thing. We are sitting on this, and we have to get 

off sitting on it and do something about it. 

Thank you. 

Senator RUBIO. Thank you, Senator Boxer. 

Let—we will begin with our testimony. 

Ms. Garber—Assistant Secretary Garber. 

STATEMENT OF HON. JUDITH G. GARBER, ACTING ASSISTANT 

SECRETARY, BUREAU OF OCEANS AND INTERNATIONAL ENVIRONMENTAL AND SCIENTIFIC AFFAIRS, U.S. DEPARTMENT 

OF STATE, WASHINGTON, DC 

Ambassador GARBER. Thank you, Chairman Rubio, Ranking 

Member Boxer, and distinguished members of the subcommittee. 

We really appreciate the opportunity to testify today on the State 

Department’s response to the Zika virus outbreak. 

I have a longer statement that I would like to submit, with your 

permission. 

With regard to the current situation, 40 countries and territories 

in the western hemisphere are experiencing active mosquito-borne 

transmission of the Zika virus. Several countries and territories in 

Africa and Asia are also experiencing outbreaks for the first time. 

Since this epidemic began, science and medical experts, my colleague Dr. Frieden foremost amongst them, have discovered the 

truly heart-wrenching impacts that this virus can have on its victims, and particularly on developing fetuses. 

As you mentioned, Mr. Chairman, this is a silent outbreak. We 

do not see hospitals full of ill patients or hear ambulance sirens in 

the street. Across the hemisphere, pregnant women and their partners are living in fear, fear that their child may be born with severe developmental defects. 

In addition to the tremendous emotional and health toll of this 

epidemic on families and communities, the demographic and economic consequences are still emerging. The cost of lifetime support 

for children affected by Zika as well as adults experiencing 

Guillain-Barre syndrome or other neurological effects could significantly tax national health and education systems. Areas with high 

poverty levels and dense population are most vulnerable to Zika, 

but least able to manage the consequences. 

The U.S. Government is committed to helping prevent, detect, 

and respond to the Zika virus, both at home and abroad. Countries 

around the world look to the United States as a leader in global 

health security, and we are working with countries in the Americas 

and beyond to provide tailored support. 

Many countries in the region have governments and strong public health systems capable of mounting a response to Zika. Countries such as Brazil, Panama, and Colombia host respected research institutions with which we are partnering to learn more 

about the virus and develop countermeasures. Through regional institutions such as the Pan American Health Organization and the 

Organization of American States, the U.S. Government and our 


FOREI-42327 with DISTILLER
7 

neighbors are leveraging our collective expertise to share best practices and identify innovative tools for vector control and disease diagnosis. In countries such as Haiti, El Salvador, Guatemala, Honduras, and the Dominican Republican, the United States is providing more direct assistance to effectively respond to the Zika 

virus threat. Our embassies are working closely with these governments and international organizations such as the World Health 

Organization to identify capacity gaps and prioritize assistance. 

U.S. voluntary contributions and other support to our regional 

and multilateral partners enable us to leverage U.S. funding and 

amplify the impact of our efforts. In addition, public/private-sector 

partners can help respond where—in areas where the U.S. Government has limited access or resources. And today at the State Department, we hosted an excellent public-private partnership event 

on just this topic. 

The State Department is committed to protecting the safety and 

security of all U.S. citizens. This also means working with other 

governments to attack the Zika virus outbreak at its source. By cooperating with other countries on Zika public-health emergency response and planning, we help build a stronger global response to 

protect U.S. citizens and the international community while contributing to international stability. If we can control an infectious 

outbreak quickly, either at home or abroad, we help limit its impact on U.S. citizens. 

So we are working with other governments to increase surveillance and diagnostic capacity, to scale up vector control, and to cut 

off the transmission cycle. We are pushing out across multiple platforms the information needed for our citizens and nationals to 

make informed travel decisions and to help to protect them from 

contracting Zika while overseas on the basis of CDC guidance. This 

is particularly true in the case of the Olympics in Brazil, where we 

expect over 100,000 U.S. citizens to attend. And Brazil is working 

very hard to protect the health and safety of all athletes and spectators attending the Olympics and Paralympics, including through 

its own public awareness campaigns and vector-control efforts. 

Zika, like Ebola before it, has highlighted how interconnected we 

are as a global community. We have a window of opportunity to address the urgent needs now, before we put at—we are put at further risk, by working with our international partners and reaffirming leadership in the region. As Secretary Kerry said at the Global 

Health Security Agenda Summit in 2014, in an interconnected 

world, we invest in global health, not simply as a matter of charity 

or as a matter of moral responsibility, but we do it as a matter of 

national security. 

Thank you for your consideration, and I welcome the opportunity 

to answer any questions you may have. 

[Ambassador Garber’s prepared statement follows:] 

PREPARED STATEMENT OF JUDITH G. GARBER

Chairman Rubio, Ranking Member Boxer, and distinguished Members of the Subcommittee, thank you for the opportunity to testify today on the international Zika 

virus outbreak response and the U.S. Department of State’s contribution to those 

efforts. 

Forty countries and territories in the Western Hemisphere, including the Commonwealth of Puerto Rico and the U.S. Virgin Islands, are currently experiencing 


FOREI-42327 with DISTILLER
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active, mosquito-borne transmission of the Zika virus. Several countries and territories in Africa and Asia are also experiencing outbreaks for the first time, including 

outbreaks of the epidemic strain circulating in the Americas. It is likely only a matter of time before we experience local transmission in the continental United States 

and Hawaii as well. 

In the short time since this epidemic began, international science and medical experts—my colleague Dr. Frieden foremost amongst them—have sought to understand the truly devastating impacts that this virus can have on its victims, and particularly on developing fetuses. It will be years before we know the full extent of 

what physicians are now calling ‘‘Congenital Zika Syndrome.’’ 

IMPACTS ON THE WESTERN HEMISPHERE

This is a silent outbreak: We do not see hospitals full of ill patients or ambulances 

in the streets, but across the hemisphere, pregnant women and their partners are 

living in fear—fear that their child may be born with severe developmental defects, 

fear that they cannot do enough to protect their families, and fear that they will 

be unable to financially care for a child suffering from Congenital Zika Syndrome. 

The Brazilian government has reported a surge in children born with microcephaly 

or other central nervous system defects; many more could be affected across Central 

and South America and the Caribbean this summer. 

In addition to the tremendous emotional and health toll this epidemic has had on 

families and communities, the demographic and economic consequences are still 

emerging. In the longer term, the cost of lifetime support for children affected by 

Zika as well as adults experiencing Guillain-Barre ́ Syndrome or other neurological 

effects could significantly tax national health and educational systems. Areas with 

high poverty levels and dense population are most vulnerable to Zika infection, but 

also least able to manage the consequences. Even with government assistance, affected families, and particularly women, may face economic hardship. 

MITIGATING THE CONSEQUENCES OF THE OUTBREAK

Countries around the world look to the United States as a leader in global health 

security, and we are working with countries in the Americas and other international 

partners to provide targeted, customized support to those affected or threatened by 

the virus. 

As a result of strong development progress in the region in recent decades, countries have strong public health systems and governments capable of mounting a response to Zika. Countries such as Brazil, Panama, and Colombia host respected research institutions with which we are partnering to learn more about the virus and 

develop countermeasures. Yet the ubiquity of the mosquito vector and its resilience 

against traditional vector control methods poses a tremendous challenge to governments and international organizations seeking to contain the outbreak. Through regional institutions such as the Pan-American Health Organization (PAHO), the Organization of American States (OAS), the Caribbean Public Health Agency 

(CARPHA), and the Inter-American Development Bank (IDB), the U.S. government 

and our neighbors are leveraging our collective expertise to share best practices, define priorities, and identify innovative tools for vector control and disease diagnosis. 

Other countries such as Haiti, El Salvador, Guatemala, Honduras, and the Dominican Republic will benefit from more direct assistance to effectively respond to 

the Zika virus threat and help prevent congenital infection. This includes capacity 

building and training for vector control, support for social and behavior change communication, support for family planning and maternal and child health interventions and services delivery, surveillance, disease detection, and monitoring and evaluation. Our embassies are working with these governments and international organizations to identify key capacity gaps and prioritize assistance. 

U.S. voluntary contributions and cooperation with the World Health Organization 

and other multilateral partners also stimulates global donors and amplifies the impact of our efforts. Crucially, multilateral, non-governmental, and private sector organizations can help extend response efforts to areas where the U.S. government 

has limited access or resources. 

PROTECTING U.S. CITIZENS

Cooperating with other countries on Zika public health emergency response and 

planning helps build a stronger global response to protect U.S. citizens and the 

international community, while contributing to international stability. If we can control an infectious disease outbreak quickly, either at home or abroad, we can help 

minimize the spread within the United States and limit its impact on U.S. citizens. 


FOREI-42327 with DISTILLER
9 

Millions of U.S. citizens live and travel overseas within the Western Hemisphere 

each year, including U.S. government employees and military personnel. The State 

Department is committed to ensuring the safety and security of all U.S. citizens, 

and utilizing all available platforms to provide the information they need to make 

informed travel decisions and protect themselves from mosquito bites and other 

forms of Zika transmission while overseas. The U.S. government must also take a 

pro-active approach, working with host governments to increase surveillance and diagnostic capacity, to scale up vector control, and to cut off the transmission cycle 

by providing information and access to voluntary family planning services, mosquito 

repellants, and other personal protective commodities. 

With the Olympics and Paralympics coming up in Brazil, we anticipate that over 

100,000 U.S. citizens will attend. All travelers to the Olympics should follow the recommendations outlined in the CDC’s travel notice. Brazil is working very hard to 

protect the health and safety of all athletes and spectators attending the Games in 

Brazil, including through public awareness campaigns and vector control efforts at 

Olympic sites. The Brazilian Government has also emphasized that the Olympic 

Games will take place during Rio de Janeiro’s winter, when the population of mosquitos is low. On June 14, the World Health Organization, at the third meeting of 

the International Health Regulations Emergency Committee on Zika, concluded that 

there is a very low risk of further international spread of Zika virus as a result of 

the Olympic and Paralympic Games. The WHO and the CDC have stated available 

evidence does not indicate there would be any meaningful public health impact from 

altering the schedule for the Games. The CDC recommends that pregnant women 

not attend the Olympics. 

CONCLUSION

The United States is fortunate to have forewarning of the tragic outbreak that 

continues to spread northward. Zika, like Ebola before it, highlights how interconnected we are as a global community and shines a spotlight on the urgency with 

which we must fill the gaps in our collective preparedness. We have a window of 

opportunity to address the urgent needs now, before we are put at further risk, by 

working with our international partners and reaffirming our leadership role in the 

region. As Secretary Kerry said at the Global Health Security Agenda Summit in 

2014, ‘‘in an interconnected world, we invest in global health not simply as a matter 

of charity or as a matter of moral responsibility, but we do it as a matter of national 

security.’’ 

Thank you for your time and consideration. I welcome the opportunity to answer 

any questions you may have. 

Senator RUBIO. Thank you. 

Dr. Frieden. 

STATEMENT OF DR. TOM FRIEDEN, DIRECTOR, CENTERS FOR 

DISEASE CONTROL AND PREVENTION, ATLANTA, GEORGIA 

Dr. FRIEDEN. Thank you very much, Chairman Rubio, Ranking 

Member Boxer, members of the committee. 

With your permission, I will submit the written statement for the 

record. 

CDC works 24/7 to protect Americans from threats. We use the 

best of modern science. Zika is both unprecedented and tragic. 

Never before have we known of a situation when a single mosquito 

bite could result in a devastating birth defect. The top priority in 

the response to Zika is to protect pregnant women. We are literally 

learning more about Zika every day, and, in the 6 months of our 

response, we have learned and done a number of things to protect 

Americans better. We wish we had a more rapid and robust support for funding to do even more. I will go through those ten things 

very quickly. 

First, the Zika response is extraordinarily complex. We have almost every center at CDC involved, more than 1,000 of our top scientists—this involves our Birth Defect Center, our vector-control 

work, our laboratory work, obstetrical work, information on sexual 


FOREI-42327 with DISTILLER
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transmission, mosquito control, virology, laboratory production—to 

identify the best methods in each community to protect pregnant 

women. 

Second, it is now definitive that Zika causes both microcephaly 

and other severe birth defects, and that it does so whether or not 

the infected pregnant women—woman had symptoms of Zika during the infection. This led us to rapidly issue travel guidance, literally within days of first seeing the Zika virus in the brains of infants who had died from the Zika infection, and to provide guidance and education to providers and women of childbearing age 

and their partners. With additional resources, we would be able to 

better understand the mechanisms of that harm and the full range 

of harm. We do not know what happens to infants born with normal-sized heads to mothers who were infected with the Zika virus, 

and we may not know that for months or years, but we need to 

begin those studies now. 

Third, as mentioned, asymptomatic illness in pregnancy can 

cause a birth defect. And that is why we have very detailed guidance for what doctors should do for testing of pregnant women who 

may have been exposed. 

Fourth, Zika almost certainly causes the Guillain-Barre syndrome. We will know more soon. A variety of infections cause 

Guillain-Barre syndrome. It would not be a surprise for Zika to be 

associated with that. The really new and different thing about Zika 

is the connection to birth defects. As a result, with other parts of 

the Department of Health and Human Services, we are planning 

for an increase in the number of cases in Puerto Rico and possibly 

elsewhere. 

Fifth, we recognize that diagnosing Zika is hard, but we have 

made lots of progress. CDC laboratory experts have created the 

tests that are being used in more than 100 laboratories around the 

United States and nearly 100 countries around the world. We have 

produced nearly 1 million test-kit materials for testing. And we 

have identified more about how to do that more accurately. However, testing for Zika is difficult. Viral loads tend to be low in 

serum, and we have learned that more is needed to do a better job 

testing. There is currently no test that can determine whether 

someone had Zika infection months or years before. We need to accelerate work on that basic question. 

Fifth, sorry, sixth vector control is even harder. The mosquito 

that causes Zika is difficult to stop. We see that, in Puerto Rico, 

the mosquitoes are resistant to just about all of the most common 

insecticides used. It is critically important that we strengthen mosquito monitoring and control in the U.S., in the territories, and 

learn more about how to do a better job stopping mosquitoes from 

spreading. This is something which additional resources would be 

very helpful in. 

Seventh, there are other routes of transmission. It is also the 

first time we have identified a mosquito-borne disease that can also 

be sexually transmitted. And that has implications for the sexual 

partners of women who are pregnant. So we have had additional 

guidance there. It is also clear that it can potentially be spread 

through blood. So we have worked carefully with the FDA, with the 


FOREI-42327 with DISTILLER
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blood banks of the U.S., to ensure that the blood supply is safe in 

this country. 

Eighth, Puerto Rico is being singled out by the mosquito. Today 

in Puerto Rico, dozens and potentially as many as 50 additional 

pregnant women will become infected with the Zika virus. Puerto 

Rico has been dealt a difficult hand because of its environment, 

and it is critical that we do everything we can to protect pregnant 

women there now. 

Ninth, globalization and urbanization are driving the spread of 

Zika, as well as cholera, yellow fever, and other diseases. It is the 

latest in a series of unpredicted and unpredictable health threats. 

What is predictable is that we will have new health threats, and 

we need a way to respond rapidly and robustly to identify problems 

where they first emerge, and stop them when they first come out. 

And tenth, we have seen a remarkable capacity within CDC for 

innovation—new laboratory tests, new mosquito-control methods. 

Every day, we are discovering new ways, better ways to protect, detect, and respond to Zika. We are committed to ensuring that the 

American people have the most accurate, up-to-date information. 

And I look forward to answering your questions. 

[Dr. Frieden’s prepared statement follows:] 

PREPARED STATEMENT OF DR. TOM FRIEDEN, 

INTRODUCTION

Good morning Chairman Rubio, Senator Boxer, and members of the subcommittee. Thank you for the opportunity to testify before you today on Centers for 

Disease Control and Prevention’s (CDC’s) efforts to prepare for and respond to the 

Zika virus outbreak, which threatens the United States and the rest of the Americas. 

The administration has requested approximately $1.9 billion in emergency funding to respond to the Zika virus outbreak in support of both the domestic and international response. 

CDC is the nation’s health protection agency, working 24-7 to save lives and protect people against unpredictable threats such as the Zika virus. Nature is a formidable adversary, and Zika is our newest threat, particularly to pregnant women. 

CDC has some of the world’s leading experts both in diseases spread by mosquitos 

and in birth defects. We must act swiftly to track and respond to the Zika virus, 

both domestically and globally. While we are learning more about the Zika virus 

every day, there are many things we do not know yet about Zika. These include our 

understanding the effects of Zika infection during pregnancy just how the virus 

causes microcephaly, a severe birth defect that is a sign of a problem with brain 

development, as well as the effects of Zika infection on the development of GuillainBarre ́ syndrome (GBS) and other possible complications. In addition to answering 

these questions, we are also working to accelerate optimal mosquito control strategies, improve laboratory testing and assure preparedness for rapid detection, control, and prevention within the United States and U.S. territories. 

We are making advances in these areas and need the additional requested funding to do so. Much of what we know about Zika and similar viruses today is based 

on the work that’s been done by CDC scientists. We are learning more about Zika 

literally every day, and will share information—and adjust our guidelines and recommendations—as we learn more. That is the nature of a scientific response to an 

emerging health threat. The doctors, scientists, laboratory experts, entomologists, 

disease control specialists, and others at CDC and other key Department of Health 

and Human Services (HHS) agencies are working nonstop to protect Americans from 

this and other health threats. We are committed to providing the American people 

with the most accurate and timely information about Zika virus, the current outbreak, and about what to expect here in the continental United States. 

It’s very important that Americans remember the core prevention message: If 

you’re pregnant, you should not travel to a place where Zika is spreading, and if 

you are pregnant and in a place where Zika is spreading, do everything you can 

to avoid mosquito bites. In addition, if you are pregnant, you should either refrain 


FOREI-42327 with DISTILLER
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from sex with a partner who has been in an endemic area or use a condom every 

time you have sex during your pregnancy. 

Most people infected with Zika virus appear to have no symptoms, and most of 

those with symptoms have only mild symptoms such as fever, rash, joint pain, and 

red eyes or conjunctivitis—that last no more than a week. Zika virus infection is, 

however, a cause of microcephaly and other severe fetal brain defects and is associated with serious health outcomes for babies of women infected during pregnancy, 

even when the woman has no symptoms. In addition, Guillain-Barre ́ syndrome has 

been reported following Zika virus infection, although a causal link has not yet been 

definitively established. CDC is investigating the link between Zika and GBS. GBS 

is very likely triggered by Zika in a small proportion of those infected, much as it 

is after a variety of other infections. 

CDC’s key priority in responding to this epidemic is to reduce the risk of Zika 

virus infection to pregnant women. CDC is acting based on what we know and, at 

the same time, undertaking research to better prevent adverse health outcomes in 

the future. That’s why, during the same week we identified Zika in brain tissue 

specimens, CDC advised pregnant women not to travel to affected areas. 

CURRENT STATUS

While we have not yet seen transmission of the Zika virus by mosquitoes within 

the continental United States, many returning travelers to the US have been infected with Zika virus. As of July 6, 1,132 cases of travel associated Zika virus infections have been reported in US states and the District of Columbia. Also, as of July 

6, 2,534 cases of Zika virus infections associated with mosquito-borne local transmission have been reported in the US territories, mostly in Puerto Rico. During the 

same timeframe, 320 cases of Zika virus infection have been reported among pregnant women in the United States and 279 infections have been reported among 

pregnant women in US territories. We know also, that a small number of cases can 

be attributed to sexual transmission. 

CDC is also reporting the outcomes of pregnancies with laboratory evidence of 

possible Zika virus infection in the U.S. states, DC and the territories. As of June 

30 there have been seven live born infants and five pregnancy losses with birth defects reported to CDC’s US Zika Pregnancy Registry. As of the same date, one pregnancy loss with birth defects has been reported by the territories to either the US 

Zika Pregnancy Registry or to the Puerto Rico Zika Active Pregnancy Surveillance 

System. 

CDC urgently needs a surge of resources to prevent and control the spread of Zika 

virus in the U.S. Commonwealth of Puerto Rico and the U.S. Virgin Islands, and 

other U.S. territories. The population of Aedes aegypti mosquitos, the primary vector for Zika virus infection, is widespread on these islands. Protective environmental 

factors such as window screens are not as prominent in the territories, and the density of people puts people there at high risk for transmission. All three areas have 

already reported local mosquito-borne Zika transmission. CDC has deployed staff to 

the U.S. Virgin Islands, American Samoa, and Puerto Rico to support response activities and provide technical assistance to health departments there. 

Furthermore, Aedes mosquitos are found in many areas of the continental United 

States, raising the risk of local transmission. Recent clusters of locally-transmitted 

dengue virus disease in the United States reinforce that Zika outbreaks in the continental U.S. may be relatively small and localized due to protective factors like window screens and less dense living conditions. However, any local outbreak will be 

of deep concern to the people living there, and we must be prepared for different 

scenarios including more extensive transmission risk. Local transmission of Zika 

will occur when a mosquito bites someone who is infected with Zika, likely someone 

infected during travel to a Zika-affected areas, and later bites another person, 

spreading the virus. There are about 40 million people travelling between the continental U.S. and Zika-affected areas each year. 

WHAT CDC IS DOING

WHO has declared Zika a public health emergency and pregnant women, especially, need to be protected from its effects. To prevent and track Zika virus infection, CDC is conducting surveillance of the spread of the virus, developing and distributing better diagnostic tests, working with states and localities to improve mosquito control and tracking, assisting Puerto Rico and other territories, issuing travel 

guidance, and providing clinical guidance on Zika. CDC experts are also working to 

protect pregnant women by better understanding the link between Zika infection 

and adverse health outcomes. 


FOREI-42327 with DISTILLER
13 

Surveillance is essential to monitor and quickly identify areas with local transmission. Most of CDC’s surveillance for arboviruses, including Zika, is captured 

through ArboNET, an integrated network which is used to monitor incidence of disease, conduct human case investigations, collect and test mosquitoes, and perform 

laboratory analysis. CDC’s Epidemiology and Laboratory Capacity Cooperative 

Agreement supports ArboNet, including funding staff in 49 states, Puerto Rico, and 

six large municipalities. Zika infection is now a nationally notifiable disease, meaning states report all identified cases of Zika infection to CDC. 

While we know Zika infection causes microcephaly and other fetal anomalies, we 

do not fully understand how, or if, there are important cofactors for these adverse 

outcomes. CDC is working to improve our understanding of the spectrum of effects 

of Zika infection during pregnancy (i.e., whether children born with normal-sized 

heads might have other neurological damage, which may not be apparent for 

months or years), just how the virus causes microcephaly, the duration of Zika infectivity in semen, and why some but not all women infected during pregnancy give 

birth to infants with microcephaly. A child born with microcephaly can cost up to 

an estimated $10 million to care for over their lifetime, and can have devastating 

effects on families and communities who must care for them. In addition to surveillance for Zika cases, CDC is working with the states and territories on surveillance 

of pregnancies with evidence of Zika infections and pregnancy outcomes through the 

U.S. Zika Pregnancy Registry and the Puerto Rico Zika Active Pregnancy Surveillance System. These are unique and unprecedented systems which can monitor 

pregnant women and their families and support health departments which provide 

care to these families. CDC is also planning a prospective cohort study in Colombia 

to evaluate the risk of maternal, fetal, and neonatal complications of Zika infection 

in pregnancy according to when during the pregnancy the infection occurred. This 

study will complement an ongoing multi-country study supported by the National 

Institutes of Health (NIH) to evaluate the magnitude of health risks that Zika virus 

infection poses to pregnant women and their developing fetuses and infants. 

CDC, along with other HHS agencies and private sector partners, has worked 

around the clock to develop and ship diagnostic tests to detect Zika virus infection. 

CDC currently has two different Emergency Use Authorizations (EUAs) from the 

Food and Drug Administration (FDA), one for the MAC-ELISA test, which measures 

the body’s immune response to the virus (issued February 26, 2016 and reissued on 

June 29, 2016) and the other for the Trioplex rRT-PCR assay, which identifies the 

acute presence of the virus (issued March 17). These tests have been distributed 

through the CDC Laboratory Response Network (LRN). The LRN is an integrated 

network of domestic and international laboratories that can respond to biological 

and chemical terrorism and other public health emergencies. In addition to use in 

the United States, many other countries were provided the CDC assays necessary 

to run these tests. In the United States, Zika diagnostic tests are now also available 

through commercial laboratories. CDC is working to increase laboratory capacity in 

the United States to handle the surge capacity needs posed by the Zika virus. CDC 

remains open to collaboration and assisting partners, including private industry, in 

their endeavors to bring accurate and precise Zika diagnostic assays to market. 

Many states and localities have existing mosquito control programs. CDC provides 

technical expertise on mosquito control strategies, including the best methods to 

control immature and adult mosquitoes, monitor resistance to insecticides, conduct 

mosquito surveillance, and monitor efficacy of control efforts. Expanded capacity has 

also been provided to states through the Epidemiology and Laboratory Capacity for 

Infectious Diseases Cooperative Agreement, Public Health Emergency Preparedness 

Cooperative Agreement, and federal vector control contracts to extend mosquito surveillance and control. In collaboration with the U.S. Departments of Defense, Agriculture, and Homeland Security, as well as the Environmental Protection Agency, 

HHS is working across its Operating Divisions to accelerate mosquito control research and to coordinate response efforts in the territories, as well as in the continental United States and Hawaii. 

Puerto Rico has a particular challenge when it comes to vector control and mosquito-borne disease. Dengue and chikungunya, which are spread by the same mosquito, have spread rapidly throughout the island, and insecticide resistance is common. Now, dozens of pregnant women are infected every day with Zika virus, and 

we are very concerned about what the coming months will hold. We are working 

with our partners in the Puerto Rico government, private industry, and other federal agencies to reduce the risk from mosquitoes spreading Zika in the territory. Activities include using CDC-developed mosquito traps, conducting indoor and outdoor 

residual spraying, distributing personal protection tools to pregnant women in Zika 

Prevention Kits, and amplifying our public education efforts. 


FOREI-42327 with DISTILLER
14 

CDC has issued 49 travel notices related to Zika. These are Level 2 travel health 

notices, advising travelers to practice enhanced precautions, with additional guidance for women who are pregnant or are trying to become pregnant. Pregnant 

women should postpone travel to regions with ongoing Zika virus transmission. If 

they must travel, or if they live in affected areas, CDC recommends pregnant 

women talk to their doctors or other healthcare providers first and to prevent mosquito bites. Reducing exposure to mosquitoes is important for anyone traveling to 

or residing in areas where the virus is circulating. Wearing long sleeves, long pants, 

using EPA-approved repellents such as DEET and permethrin-treated clothing (both 

of which are safe to use during pregnancy), and using other protections such as airconditioning and window screens will reduce exposure to daytime mosquitoes. Given 

the potential for Zika virus to be spread through sex, pregnant women and their 

male partners living in or who have been to Zika-affected areas should abstain from 

sex or use condoms for the duration of the pregnancy. 

CDC also has provided guidance for doctors and other clinicians on evaluation, 

treatment, and follow-up care of pregnant women and infants with possible exposure to Zika virus, partnering with organizations from the health care community 

to help distribute this information as widely as possible. 

This is a rapidly changing situation and our understanding of the risks concerning 

Zika virus infection is incomplete and evolving. As we get new information, we will 

update our advice. 

COORDINATION AND PARTNERSHIPS

CDC is working closely with health departments across the country and in the 

territories to support and coordinate its efforts and to expand capacity for detecting 

and responding to Zika virus. Strong collaboration with states and local partners is 

critical to an effective response. CDC is helping states assess and expand capacity, 

while engaging stakeholders including healthcare providers, blood banks, vector control organizations, medical associations, schools, employers, and others. We are continuously refining and improving our recommendations based on issues identified 

during the CDC-hosted Zika Action Plan Summit for state and local health officials 

and continued feedback from states. 

I also want to acknowledge our federal partners. I have mentioned a few already. 

CDC is working in collaboration with other components of HHS including the Office 

of the Assistant Secretary for Preparedness and Response (ASPR) and its Biomedical Advanced Research and Development Authority (BARDA), the Office of the 

Assistant Secretary for Health, the NIH, who are working to develop a vaccine, and 

the FDA We are also working with partners across the U.S. Government, including 

the Department of State, the Department of Homeland Security, the Department of 

Veterans Affairs, and the Environmental Protection Agency, to communicate with 

travelers and health care providers, update travel alerts and clinical guidance, and 

develop improved mosquito-control methods. 

OLYMPIC GAMES

CDC and the United States Olympic Committee (USOC) signed a memorandum 

of understanding on May 27, 2016, and are working together to communicate risks 

and protective actions that can be taken before, during, and after travel to the 2016 

Olympic Games in Brazil. The target audience for CDC’s outreach efforts include 

Olympic and Paralympic athletes, staff, and delegation members. Our guidance for 

the general public for travel to the Olympics is the same guidance we have issued 

for travel to Brazil and other areas with Zika. While many Americans will travel 

to Brazil for the Olympics, travel to the Olympics is only a small fraction of overall 

global travel to countries that have ongoing Zika transmission. Travel to the Olympic Games represents about 0.25 percent of total aviation travel annually to Zikaaffected areas. 

CDC’s communication actions for the Olympics include webinars to National Governing Body staff to share Zika prevention and travel health information, hosting 

an in-person informational booth during out-processing in Houston, co-branded print 

materials tailored to the U.S. delegation, a customized CDC website with content 

tailored to National Governing Body needs, social media messages disseminated 

through USOC channels, and short videos on packing clothing for prevention. 

In addition to Zika prevention guidance, CDC also has posted general guidance 

for all travellers to the 2016 Summer Olympic and Paralympic Games in Brazil. 

Guidance for travel to the Olympics includes information about travel vaccines, safe 

food and water practices, and safety and security in crowds. 

As we continue to learn more about the Zika virus, we will update our guidance 

and recommendations for the 2016 Olympic and Paralympic Games as appropriate. 


FOREI-42327 with DISTILLER
15 

CONCLUSION

The emergence and reemergence of health threats, including those spread by mosquitoes and other vectors, will continue for the foreseeable future. These outbreaks 

cannot be expected to occur in isolation. Puerto Rico and Hawaii were already responding to outbreaks of dengue when Zika virus emerged as an urgent health 

threat. We need to address the threat of mosquito-borne diseases systematically, 

rather than episodically. 

While we need congressional action on the President’s funding request, CDC has 

not waited for Congressional action to respond to the threat posed by Zika. We have 

made difficult decisions and redirected resources from other important public health 

activities to support our most critical needs. These redirected funds, however, are 

not enough to support a comprehensive Zika response, and they divert funding from 

other critically important public health activities. They only temporarily address 

what is needed until the Congress acts on the Administration’s emergency supplemental request. Without the full amount of requested emergency supplemental 

funding, many activities that need to start now may have to be delayed or stopped 

within months, or may not occur at all. We need to start now to do the work to 

better understand the link between Zika disease and birth defects; track the spread 

of mosquitoes in the U.S. and control them before the epidemic spreads here; support states and territories to prevent and manage cases of Zika, diagnose patients, 

and increase lab capacity; and better understand, develop, and more fully deploy 

laboratory testing and for mosquito control. 

We are hopeful that Congress will work quickly to fund critical response efforts 

to protect pregnant women against Zika. 

Senator RUBIO. Thank you, Dr. Frieden. 

Ms. Koek. 

STATEMENT OF IRENE KOEK, ACTING DEPUTY ASSISTANT ADMINISTRATOR, U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT, WASHINGTON, DC 

Ms. KOEK. Thank you, Chairman Rubio, Ranking Member Boxer, 

and distinguished members of the subcommittee, for inviting me 

here today to testify on USAID’s response to the Zika virus outbreak. I want to thank you for your continued leadership and commitment to this issue. 

I will submit a written statement for the record, but today I 

would like to briefly describe USAID’s work with the U.S. Government and regional international partners to address Zika. 

Our aim is to minimize the negative pregnancy outcomes associated with Zika infection. Our efforts are focused on countries at 

risk for adverse outcomes from Zika that have relatively weaker 

government capacity to respond to Zika and where we expect that 

governments will want support from the United States. Our toptier priorities include Haiti, Guatemala, El Salvador, Honduras, 

and the Dominican Republic. 

Our strategy has four interconnected lines of effort: vector control, social and behavior change, service delivery related to maternal and child care and family planning, and innovation. 

In vector control, our activities aim to improve and expand existing vector management efforts in Zika-affected or at-risk countries 

to reduce the Aedes mosquito populations. We will implement 

household and community-level vector control, helping those at risk 

learn to eliminate sources of standing water in which the Aedes 

mosquitos breed, scrub containers for mosquito eggs, and apply larvicide to water sources that cannot easily be eliminated. 

For social and behavior change in community engagement approaches, put the community at the forefront of managing their 

risks, and prevention and management of the disease, and are of 


FOREI-42327 with DISTILLER
16 

critical importance. We will give people the tools and knowledge to 

adopt personal protection, protective behaviors, including the use of 

repellents, long-sleeved clothing, and condoms, seek care, and help 

with community response. 

Our service delivery approach begins before a woman becomes 

pregnant by ensuring that women in Zika-affected areas who may 

wish to delay or limit future pregnancies can access family-planning information and services. For women who are currently pregnant, providers must be trained to counsel them and their partners 

on the need to prevent sexual transmission of Zika through condom 

use. Once a woman becomes pregnant or has a baby in a Zika-affected area, USAID is committed to ensuring that she receives costeffective, high-quality maternal and child health services, with an 

emphasis on respectful care of pregnant women and infants with 

suspected congenital Zika syndrome. 

Innovations are critically needed to mitigate the spread and impact of Zika virus and improve our ability to prevent, detect, and 

respond to future infectious disease outbreaks. 

While we are utilizing all the tools in our toolbox to mitigate the 

impact and spread of Zika virus, many of those tools have limitations. As such, USAID worked quickly to launch a new Grand 

Challenge called Combating Zika and Future Threats. We received 

over 1,000 responses and believe we have some very exciting options. We expect to begin making awards by the end of this month 

or in early August. 

So far in our programming efforts, we have completed a new interagency agreement with CDC and transferred $78 million to 

enable them to start on critical surveillance and research activities. 

And we have obligated $18 million to partners to work primarily 

in service-delivery and behavior-change areas. We are also working 

with UNICEF and PAHO in the region and with the World Health 

Organization in Geneva to address growing needs on a global level 

and outside of the western hemisphere. By the end of this month, 

we expect to begin our vector-control activities. In August and September, our community engagement activities will be rolled out. 

We have designed our efforts to ensure they solidify the legacy 

of USAID’s 50-year history of health assistance gains in the region. 

USAID is committed to addressing the Zika virus outbreak of today 

and strengthening capacities to ensure that this threat will be mitigated as much as possible. 

Thank you for the opportunity to speak with you today. I am 

happy to answer any questions. 

[Ms. Koek’s prepared statement follows:] 

PREPARED STATEMENT OF IRENE KOEK

Thank you Chairman Rubio, Ranking Member Boxer and distinguished members 

of the subcommittee for inviting me here today to testify on the U.S. Agency for 

International Development’s (USAID) response to the Zika virus outbreak. I want 

to thank you for your continued leadership and commitment to global health and 

global development issues. We see you as partners in USAID’s mission to end extreme poverty and promote resilient, democratic societies while advancing our security and prosperity. 

Zika cases currently have been identified in 49 countries, 40 of them in the Americas. More than 298 million people live in Zika-suitable transmission zones within 

the Americas. In 2015, over 5.4 million births occurred in these environmentally 

suitable areas and during times of year when transmission is most likely to occur. 


FOREI-42327 with DISTILLER
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Additionally, summer peak travel between the United States and the countries of 

Central America, and the Caribbean coincides with peak seasonal mosquito abundance. We do not yet know the extent to which pregnant women or their children 

in much of the region have been affected. While there is still a great deal to understand about Zika, and the current set of tools we have are limited, there is still 

much we can do to help those at risk protect themselves and reduce the impact of 

Zika on pregnant women and their babies. 

Today, I would like to briefly describe USAID’s work at country, regional and 

global levels with partners in the U.S. government and with regional and international partners, I will also share with you some of the opportunities and challenges that we are all facing. 

USAID has been working closely with partners across the U.S. government to implement our collective response to the Zika outbreak. This collaboration aims to 

minimize the number of pregnancies affected by Zika virus transmission. Together, 

U.S. government agencies plan to undertake surveillance efforts to identify the progression of the Zika virus, diagnose infections when they occur, provide care and 

support for pregnant women who have been identified as having contracted the Zika 

virus, and take efforts to prevent further infections. We are also working jointly to 

accelerate innovation and research across each of these categories of response. 

Most of these international efforts are being undertaken with $211 million that 

USAID reprogrammed from the planned Ebola response effort. Of that total, USAID 

has provided $78 million to our colleagues at the Centers for Disease Control and 

Prevention (CDC) to capitalize on their expertise in surveillance, laboratory testing, 

public health response, and entomology to ensure accurate detection of infections 

and evaluation of Zika control measures. We also count on CDC to leverage key research studies and evaluations that will help us better understand this virus. While 

Dr. Frieden may provide more details on these efforts, I think it is important to 

highlight the value of learning as much as we can about the virus. Each new piece 

of evidence allows us to more effectively shape our responses. For example, when 

we initially planned our response to Zika and submitted the Administration’s request for additional funding, we were unaware of the relative risk of sexual transmission. Now, armed with that information, we know that our efforts must target 

both pregnant women and their partners in order to be effective, and we have adjusted our plans accordingly. 

With the balance of $133 million, USAID is working through existing country systems to reduce the risk of new infections, particularly in pregnant women, and provide care to those known to be affected. USAID has a long history of supporting 

countries in Latin America and the Caribbean, which culminated with technical assistance to ensure that health systems could be responsive to changing circumstances. In many cases, we successfully concluded nearly 50 years of assistance 

through a deliberate process that was designed to ensure that countries could effectively continue to advance the health of their populations. We know that in many 

of these countries, inequities exist and that hard wrought gains can be easily damaged by an economic or political crisis. For example, USAID’s health program in 

Honduras is successfully concluding this year, having been extended from its original end date as a result of instability constitutional crisis that occurred as we were 

just beginning our phase-out plan. Our focused efforts over the last five years of this 

graduation process successfully resulted in a 16 percentage point increase in women 

delivering their babies in healthcare facilities. Yet, the Honduran government still 

has more work to do; there is a 40 percentage point gap between the rate at which 

the richest women deliver in a facility when compared to the poorest women. Bearing this in mind, our response to Zika will seek to further support and strengthen 

country systems, including those responsible for ensuring pregnant women have access to quality prenatal care. 

We have designed our efforts to ensure that a short-term focus on mitigating the 

impact of Zika does not undermine systems, but rather solidifies the legacy of 

USAID’s impressive health assistance gains in the region. Efforts that both 

strengthen host country systems and impact Zika require a more narrow focus to 

ensure a strategic use of available resources. We want to ensure that all efforts relate directly to minimizing the negative pregnancy outcomes associated with Zika 

infection. We will do this by improving the quality of Zika prevention and care services through both public and private sector delivery channels and also by ensuring 

that communities are engaged with implementation of measures that will reduce 

the risk of Zika infection in pregnant women. 

USAID’s response is focused on four interconnected lines of effort: Innovation, 

Vector Control, Social and Behavior Change Communication, and Service Delivery 

related to: family planning, antenatal and postnatal care, as well as child developVerDate Mar 15 2010 11:01 Mar 01, 2018 Jkt 000000 PO 00000 Frm 00021 Fmt 6633 Sfmt 6621 S:\FULL COMMITTEE\HEARING FILES\2016 HEARINGS -- WORKING\071316 27-830\27-8

FOREI-42327 with DISTILLER
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ment and care for families with infants affected by Zika. I will briefly present our 

programs and approach in each of these areas: 

Vector Control 

Our activities aim to improve, expand, and focus existing vector management systems, networks, and programs in Zika-affected or at-risk countries to reduce Aedes 

mosquito populations. Preliminary findings from vector control capacity assessments 

in our priority countries indicate that the capacity of national vector control programs to conduct surveillance and vector control activities is weak and investments 

are needed to improve public health entomology and protect pregnant women. These 

assessments will be finalized in August 2016 and we will have concrete recommendations that will inform and direct our partners’ activities in this area. However, based on the preliminary results, we plan to support regional trainings and 

technical assistance to bolster inclusion of quality vector control approaches into national vector control programs, while monitoring mosquito populations for resistance 

to insecticides and to determine the effectiveness of vector control interventions. 

Through our community engagement efforts, we will implement household-to-household vector control in atrisk or affected communities. Specifically, households will 

learn how to eliminate sources of standing water in which Aedes mosquitoes breed 

and scrub containers for mosquito eggs. Larvicides will be used in standing water 

sources that cannot be easily eliminated. We will purchase and distribute the required vector control commodities to public and private sector partners, and we will 

build country capacity to conduct GPS mapping of breeding sites, which will provide 

us with information to forecast areas at heightened risk of transmission in real 

time. 

Social and Behavior Change Communication 

Social and behavior change communication and community engagement approaches put the community at the forefront of managing their risks in prevention 

and management of the disease. We have learned from previous emerging disease 

outbreaks that effective risk communication and community engagement from the 

outset and throughout the course of public health emergencies is essential for effective disease control. As an example, we saw that in order to control the recent Ebola 

outbreak, strengthening clinical services alone is not enough. We expanded our work 

with communities to better understand their cultural practices, including traditions 

around burial practices. By actively engaging communities and understanding local 

cultural practices, we were able to encourage safer behaviors, while still respecting 

community traditions and long held beliefs. These social and behavioral interventions, combined with effective biomedical interventions, played a key role in effectively controlling the outbreak. 

In order to tackle the worst effects of Zika, we will also need to earn the full engagement of at-risk communities so they are committed and effective partners in 

prevention and control activities. Our approach is aimed at enabling communities, 

households and individuals affected by and at risk of Zika to better understand their 

risks and practice key protective behaviors to minimize negative pregnancy outcomes. The overall approach will work through global, regional, national, and local 

levels to implement effective social and behavior change interventions designed to 

minimize negative pregnancy outcomes by focusing on the most at risk and vulnerable audiences: pregnant women, women of reproductive age and their partners, in 

households and communities in lower resource settings. With community involvement and the benefit of local perspectives, we will use the most appropriate channels to encourage behaviors for personal protection including use of repellents, longsleeved clothing and condoms, to promote prevention, community response and careseeking. These activities will be closely monitored for effectiveness and adjusted 

based on the results of that monitoring. Effective messages and approaches will be 

shared region-wide. 

Service Delivery 

In order to truly mitigate the impacts of this virus, we must improve access to 

healthcare services for women of reproductive age in Zika-affected or at-risk communities. These services include antenatal and postnatal care, child development, and 

family planning services. A key component of improving access to services is improving providers’ capacity to deliver quality Zika-related healthcare and social services 

to women of reproductive age, particularly pregnant women, families, and children 

affected by Zika. Although most countries have issued Zika care guidelines, the 

rapid evolution of the evidence base requires constant updating of the guidelines, 

and the need for more specific protocols and procedures. 

Our service delivery approach begins before a woman becomes pregnant by ensuring that women, adolescents, and couples in Zika-affected areas who may wish to 


FOREI-42327 with DISTILLER
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plan to delay or limit future pregnancies can access information, services, and methods regarding family planning. We must reach women who are considering becoming 

pregnant, and may wish to delay or limit pregnancies; as well as women who have 

unmet need for family planning, and want to prevent unintended pregnancies. For 

women who are currently pregnant, providers must be trained to counsel them and 

their partners on the need to prevent sexual transmission of Zika through condom 

use. Once a woman becomes pregnant or has a baby in a Zika-affected area, USAID 

is committed to helping her receive cost-effective, high quality maternal and child 

health services, with an emphasis on respectful care of pregnant women and infants 

with suspected congenital Zika syndrome. Therefore, our work will focus on 

strengthening antenatal care services for all pregnant women including counseling 

on prevention (repellents, condoms, and other measures) and validating women’s 

fears and concerns. Within this, we will have a special focus on strengthening 

antenatal care and delivery services for women with suspected Zika infection during 

pregnancy, including psycho-social support for the family and specialized newborn 

care at delivery. Through policy-level engagement, USAID will work with partners 

and with host countries to improve awareness of Zika-linked health conditions in 

children and ensure the engagement of all relevant ministries including education, 

family welfare, etc. for the care and support of Zika-affected families and children. 

At the present time, we are not planning to focus our resources on care for children born with Zika congenital syndrome. However, this could become a growing 

area of need if we are unable to mount an effective response as soon as possible. 

As the need for this population becomes more evident or with additional resources, 

we will explore the effects of congenital Zika syndrome for infants with suspected 

cases, including the application of basic neurodevelopmental monitoring and therapy 

including early stimulation. 

Innovations 

While we are utilizing all the tools in our toolbox to mitigate the impact and 

spread of the Zika virus, many of these tools have limitations to their effectiveness 

and scalability. Aedes mosquitoes, for example, are less susceptible to standard vector control approaches like indoor residual spraying, as they tend not to rest on the 

walls where insecticides would be typically sprayed. They also can breed in the 

smallest of containers—even a plastic water bottle cap—rendering large-scale larvicide approaches impractical. Available products to protect individuals from being 

bitten require frequent replenishment or reapplication and often are unappealing to 

end users, due to factors like smell, skin or eye irritation, and comfort. And, few 

homes, schools, or other buildings have screens on their windows. As a result, 

USAID has partnered with colleagues from across the U.S. Government—from 

BARDA, CDC and NIH to the Departments of Defense and Homeland Security— 

to identify promising innovations under development within each agency and figure 

out how to bring cutting-edge technological advances to the developing country context. Within USAID we worked quickly to launch a new Grand Challenge, called 

‘‘Combating Zika and Future Threats,’’ to enhance our capabilities in both the short 

and long term by sourcing innovations that mitigate the spread and impact of the 

Zika virus and improve our ability to prevent, detect, and respond to future infectious disease outbreaks, like Zika. We sought solutions—from new ways to reduce 

mosquito populations, to new options for preventing mosquitoes from biting or 

transmitting Zika to humans, to entirely new ways to detect and respond to Zika 

infections. We sought creative ways to educate and mobilize entire communities— 

from entrepreneurs, scientists, engineers, students, and others around the world. 

We received an overwhelming response, with nearly 1,000 ideas from over 60 countries, and we are moving rapidly to identify those ideas with the most promise for 

curbing the current Zika outbreak and preventing such outbreaks in the future. 

Unfortunately, current resources do not allow USAID to implement these response efforts region-wide. We cannot even implement them in all areas most atrisk for Zika. We have chosen to focus our efforts on countries at risk for adverse 

outcomes from Zika due to predicted number of cases (based on experience with dengue and chikungunya), with relatively weaker government capacity to respond to 

those cases, and where we expect that local governments will want robust support 

from the United States. These countries include Haiti, Guatemala, El Salvador, 

Honduras, and the Dominican Republic. Within these countries we believe that we 

can rapidly scale up to full implementation of our strategic set of anticipated activities and maintain these programs for several months. However, without additional 

resources, we would be forced to choose between cutting off programming before it 

can have lasting impact in our priority countries or eliminating any impact beyond 

the priority countries. For example, in the next set of countries USAID would work 


FOREI-42327 with DISTILLER
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with, which includes Nicaragua, Jamaica, Paraguay, and Peru, we planned to fund 

technical assistance and support at the national level across the range of intervention areas. Without additional funds, these plans would need to be reconsidered 

against the consequences of stopping programs too soon in the first set of countries.. 

Our ability to truly have an impact on the spread of Zika is limited if we cannot 

cover more at-risk areas. 

We were appreciative of receiving Congressional support to move forward with the 

reprogramming of funds on April 26. In the month of May alone, we completed a 

new Interagency agreement with the Centers for Disease Control and Prevention 

and were able to transfer the full $78 million to enable them to get started on critical surveillance and research activities. We were also able to obligate an additional 

$14 million to partners to work primarily in the service delivery and behavior 

change areas. Those partners quickly began meeting with Ministries of Health in 

the five target countries; coordinating with the United Nations Children’s Fund 

(UNICEF), the United Nations Population Fund (UNFPA), and the Pan American 

Health Organization (PAHO) on national level communication strategies; conducting 

rapid assessments of existing tools and resources available to service delivery providers; assessing the capacity of countries in behavior change communication, service delivery, and vector control; as well as creating a Zika resource web platform, 

the Zika Communication Network (http://zikacommunicationnetwork.org/)—a source 

for global Zika prevention and preparedness materials as well as for research and 

development updates. In mid-June, along with partners, we kicked off a Zika-related 

discussion on the Springboard virtual platform, titled ‘‘Communicating About Zika: 

Messaging for Pregnant Women and Women of Reproductive Age,’’ that drew a 

record 700 people to the discussion, while tweets related to the discussion have 

reached over 60,000. Additionally, in our priority countries, USAID-supported private not-for-profit health organizations are developing provider training materials 

and behavior change messages at Ministries of Health request that will be applied 

in their networks and shared with the public sector. Both the private and public 

sectors are working together to align messages under the leadership of governments. 

Soon activities will be conducted to determine gaps in care processes around the 

availability and quality of family planning, antenatal and immediate newborn care 

in our focus countries. These activities will be conducted in collaboration with incountry universities, allowing us to better understand where needs are greatest and 

ensure that our response efforts are well aligned. At the same time, we are preparing to roll out online and in-person training courses to reach large numbers of 

health professionals as quickly as possible. We are also beginning partnership activities with UNICEF and PAHO in the region and with the World Health Organization in Geneva to address growing needs on a global level and outside of the Western Hemisphere. By the end of this month, we expect to be able to begin our vector 

control and entomological activities and then through August and September our 

community engagement and innovations activities will be rolled out. 

A four-month time period to initiate such a broad range of activities in countries 

and areas where USAID does not have ongoing health projects is a very fast rate 

of start up. In this time period, we will have completed the required analyses to 

ensure that our efforts comply with environmental safeguards and standards, we 

will have established new awards through full-and-open competition and made necessary modifications to other awards in order to accommodate the Zika response efforts. The current timeline means that we will not achieve full implementation until 

the end of the typical rainy season in Central America and the Caribbean. However, 

we are still confident that these resources and additional resources made available 

in the near future will allow us to be prepared with programs in place in order to 

have an immediate impact on next year’s rainy season and the upcoming rainy season in South America. And finally, the efforts I have described will serve to 

strengthen country health systems and allow us to leverage this strength for improved impact. 

CONCLUSION

USAID is committed to addressing the Zika virus outbreak of today and strengthening capacities to ensure that this threat will be mitigated as much as possible. 

Thank you for the opportunity to speak with you today and to share the contributions we are making. I am happy to answer any questions. 

Senator RUBIO. Thank you all for being here. 

I want to begin with Secretary Garber. The—Brazil’s new Health 

Minister has said that there is a almost-zero risk of athletes or 

spectators contracting Zika during the Olympics. Is this threat—is 


FOREI-42327 with DISTILLER
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the threat in Brazil truly almost zero? And what advice do you 

feel—let me ask this. Should our athletes or spectators feel fully 

safe in traveling to Brazil for the Olympics, given what we know 

about the situation there? 

Ambassador GARBER. Thank you very much, Mr. Chairman. 

We are putting out the guidance based on the CDC guidance, 

and pushing that out through all available platforms to make sure 

that travelers and the over 100,000 Americans that are planning 

on attending the Olympics can make informed decisions. We know 

the Government of Brazil is working very hard to address this outbreak through its own very aggressive public information campaigns and vector-control efforts, including through many in the 

Army, hundreds of thousands, as well as public health officials to 

work on vector control. But I would defer to Dr. Frieden, specifically, on the assessment of the risk. 

Senator RUBIO. Well, Dr. Frieden, is the chance of contracting 

Zika in Brazil almost zero for athletes and spectators? 

Dr. FRIEDEN. We recommend, for any travel, that pregnant 

women not go to areas where Zika may be spreading. We would 

recommend, for the Olympics, as we would for any other travel, 

that pregnant women not travel. For others, there are reasonable 

steps people can take to protect themselves. Historical data does 

suggest that viruses spread by this mosquito are less common in 

the period of the Olympics, but we think the key issue is not why 

people travel, but who is traveling. And the key message to get out 

there is that pregnant women should not be traveling to areas 

where Zika is spreading, and, if they are present in those areas, 

should take steps to protect themselves. 

Senator RUBIO. Well, let me ask it another way. Should athletes 

or spectators traveling to Brazil at least think about it before they 

go, given what we have known about how rapidly it has spread 

there? 

Dr. FRIEDEN. All travel involves risk. It may be from a motor vehicle crash, it may be from infectious diarrhea, it may be from dengue or other diseases. We do not think the risk will outweigh the 

travel benefits for most people, except for the group of pregnant 

women. And that is why immediately after identifying Zika in the 

brains of affected infants, we advise that pregnant women not travel to Zika-affected areas. Also important for men who have sexual 

partners who are pregnant to use condoms if they come back from 

an area with Zika. 

Senator RUBIO. Dr. Frieden, what is a reasonable timetable to 

expect a vaccine for Zika? 

Dr. FRIEDEN. We are told by the National Institutes of Health 

that they hope to be in clinical trials in September. That would 

mean that, in the next couple of years, we could have an approved 

vaccine that is both safe and effective. But only time will tell 

whether that happens. It is very promising. The immune response 

to Zika is robust, so it is certainly theoretically quite possible, but 

these things do take time. 

Senator RUBIO. You touched upon it in your statement earlier. 

And a lot of the focus on Zika, and rightfully so, has been through 

the impact that it has on microcephaly. But let me ask you—I 

know that there is a study ongoing with the Colombian government 


FOREI-42327 with DISTILLER
22 

to study the link between Zika and Guillain-Barre. Is there anything you can share with us about the preliminary findings? I saw, 

in your statement, you said that you most certainly believe that it 

will prove that there is a direct link. 

Dr. FRIEDEN. We have seen several studies published—one from 

French Polynesia. We have work going from Brazil. We expect, by 

the end of the summer, to finalize that work. I expect that that 

link will be proven, given the epidemiological patterns, but we do 

not yet have two really strong, independent studies determining it. 

That takes some time. But we have had excellent collaboration, 

both in Brazil and especially in Colombia, where we are really 

working side by side with long-term collaborators there. 

Senator RUBIO. And again, just to be clear, just so anyone who 

might be watching this now or later would understand, the 

Guillain-Barre link is on everyone. Anyone infected by Zika runs 

that risk, beyond what we are talking about now with pregnancy, 

correct? 

Dr. FRIEDEN. That is correct. It tends to increase with age, but 

anyone can be affected, and it can cause paralysis that can be severe, is usually temporary, can last from weeks to months. 

Senator RUBIO. And, Ms. Koek, you—generally speaking, the 

health systems in Latin America and the Caribbean are stronger 

than those of many sub-Saharan African nations and Southeast 

Asian nations. And this phenomenon has prompted USAID to graduate several countries from any global health programs. But there 

are some groups that have come to us that are concerned that 

Haiti and countries in the Caribbean and in the northern triangle 

of Central America may be ill-equipped to handle Zika cases as 

well as possible related complications. What direct support, if any, 

are you planning to provide these countries? 

Ms. KOEK. Thank you very much for that question, Senator. 

USAID has a long history of supporting countries in the region, 

and, as you noted, we did graduate our assistance from many countries. And that was a—following a very deliberate effort and working very closely with the governments and local partners to move 

away. And, as you noted, it was probably because of the progress 

that had been made in many of those countries, and the capacity 

had been developed. 

Haiti is still a country where we have a robust health program 

in all areas. And so we believe Haiti needs additional support. But 

as part of our program, they have already been able to move some 

of the resources they have through the USAID program to get a little bit ahead and start to respond to Zika. 

Similarly, one of the things we are doing, particularly in Central 

America, which is home to a number of our priority areas, is identifying where some of those gaps are. Zika was completely unexpected, and it does present a threat that has been discussed here 

today, figuring out where we can fill those gaps and provide the 

support needed. 

Senator RUBIO. Well, are there any countries that we—that have 

graduated from the USAID health programs, have been graduated 

in their levels, that have, nonetheless, appeared to need additional 

support as a result of Zika? 


FOREI-42327 with DISTILLER
23 

Ms. KOEK. Yes. Some of the countries that we have prioritized, 

including Honduras, El Salvador, and the Dominican Republic, are 

all countries that we have graduated assistance from, or the robust 

assistance. Those are countries we believe do need some additional 

targeted support. 

Senator RUBIO. Senator Boxer. 

Senator BOXER. Thank you, Mr. Chairman. 

Earlier this year, El Salvador issued a nationwide call for women 

to avoid pregnancy for 2 full years. Now, one can debate how real 

that could be, given what we know. But setting that aside, other 

governments in Latin America also called on women—not on men, 

on women—to avoid pregnancy. In other words, they did not tell 

the men that they should work with the women. Very typical. 

Other governments in Latin America and the Caribbean issued 

similar directives, including Colombia, Ecuador, and Jamaica. 

Those countries said, ‘‘Women, do not get pregnant for 2 years.’’ 

My question to any of you on the panel, do you believe these 

countries have the health infrastructure to give women in these 

countries, who have been told not to get pregnant for 2 years, access to free contraception? 

Ms. KOEK. Thank you very much, Senator Boxer. It is a excellent 

question, and we very much share the concerns you raised in asking this question. 

We are very committed to ensuring that women do have access 

to all the information and support and access to services. And there 

certainly are gaps. 

Senator BOXER. That is not my question. 

Ms. KOEK. Yes. 

Senator BOXER. I asked you if those countries who have told 

their women not to get pregnant for 2 years have the infrastructure 

to get free contraception to these women of childbearing age? 

Ms. KOEK. Yes. 

Senator BOXER. They are the ones who are in charge of their own 

countries. They are the ones who issued this directive to their 

women. Do they have the infrastructure? 

Ms. KOEK. I think it is a mix. Part of our graduation strategies 

in many of these countries was to make sure there was a strong 

family planning program in place, including a supply of contraceptives. 

Senator BOXER. Do all these countries have the ability to get free 

birth control to women of childbearing age? Do they have the ability to do that? 

Ms. KOEK. I think, in most cases, they have supply; but the issue 

of making sure that you are not telling women that you must use 

family planning or, as you put, putting the onus on the women, is 

certainly part of what we want to make sure happes. 

Senator BOXER. I am not asking about that. I am asking you if 

they have the infrastructure and the ability to get contraception to 

the women that they have told that they should not get pregnant 

for 2 years. Or do they need our help getting that birth control to 

them? 

Ms. KOEK. We believe the issues are mostly around the delivery. 

And that is where they do need some help. They do not need help 


FOREI-42327 with DISTILLER
24 

on supply of contraceptives. It is the delivery that presents a problem, making sure that those who are most in need have access. 

That is where the gaps are. 

Senator BOXER. How are they doing it, the ones that you say are 

doing a good job? How are they getting this contraception to the 

people who need it? 

Ambassador GARBER. If I could just provide two examples, Senator Boxer, and then I will defer back to Irene for anything additional. I am aware that, in Ecuador, for example, the government, 

through its public hospital system, does provide universal access to 

birth control. There is a delivery system in place to allow for that. 

And I was just in El Salvador last week and met with the Minister of Health there and talked a little bit with Irene’s colleagues 

from USAID about how they want to prioritize the assistance that 

we are going to be giving them. And one of the things that the Minister of Health really emphasized tremendously was trying to be 

able to provide access to birth control. 

Senator BOXER. What assistance are we going to give those countries who have told their women not to get pregnant for 2 years? 

What are we doing to provide them with free birth control? 

Ms. KOEK. We are doing a couple of things. One is to make sure 

that the supplies that are in place are actually getting to the people that need them, and that there is full access, and that information is available to the women so they can make the choices themselves. There is some policy work also to make sure the statements 

that you described are—it is not necessarily going to help give access, and that is one of the concerns we have. 

Senator BOXER. Okay. How many cases are there in El Salvador? 

Dr. FRIEDEN. We would have to get back to you with the exact 

number. 

Senator BOXER. Would you do that? 

Dr. FRIEDEN. We do know that it is only a small number of the 

total cases that have been diagnosed. 

[The information requested had not been received at the time 

this document went to press.] 

Senator BOXER. Good. And what about Colombia, Ecuador, and 

Jamaica? Do you have those stats? 

Dr. FRIEDEN. Offhand, no, but the reported numbers are, in most 

countries, only a small fraction of the total cases, since 80 percent 

of people have no symptoms at all and testing is not widely available in many of these countries. 

Senator BOXER. Well, how many babies have been born with 

anomalies in those countries? Do you have that data? 

Dr. FRIEDEN. In Brazil, where the epidemic started, you have 

had the largest number of pregnant women with infections in the 

first trimester, which appears to be the highest-risk period to come 

to term. And we have seen between hundreds and thousands of babies with microcephaly. Those are still under investigation, in 

terms of confirmation of the diagnosis. We have an investigation 

collaboratively with Colombia, where we are following a group or 

cohort of women who appear to have had Zika infection. And over 

the coming months, we will be able to determine with more certainty what the prognosis is. 


FOREI-42327 with DISTILLER
25 

Senator BOXER. Could you get back to me on the numbers of 

those countries where the countries have stated they have given 

this directive to the women and girls not to get pregnant for 2 

years, those countries I mentioned, how many cases of anomalies 

they have had? 

[The information requested had not been received at the time 

this document went to press.] 

Senator BOXER. I was telling the Chairman that I heard a report 

on one of the radio news shows that—and I just do not know if this 

is anything you are involved in or we are involved in—that, for the 

young men and women who are going to Brazil, that they are going 

to be tracked afterward and followed to see what happens with 

their health. Could—do you know anything about that? 

Dr. FRIEDEN. We have a memorandum of understanding with the 

U.S. Olympics Committee. We work collaboratively providing technical assistance, outreach, and education. They are also working 

with a university in the U.S. to do a study voluntarily for athletes 

and members of the Olympics and Paralympics who want to know, 

both before and after, whether they might have been infected. That 

might have been what that was referring to. 

Senator BOXER. Okay. 

Well, let me just say, if we know this is dangerous, so dangerous 

that we are asking these people to volunteer, we better talk to 

these people, one by one by one by one by one by one, and let them 

know how serious this is. I feel very strongly about that. I do not 

want our people being used as guinea pigs, ‘‘Oh, you come home, 

we will follow you, we are going to see whether you got this or not, 

and how—if you had any babies who have microcephaly.’’ This is 

not right. 

I would just close my frustrating comments here today by saying 

that we cannot have one hand tied behind our back by saying, as 

the House said in a completely partisan way, none of this money 

could be used for nongovernmental entities to help provide birth 

control, which is so critical. And it is wrong—a country thinks they 

solved the problem, when they just tell the women in the country 

they should not become pregnant. There is something wrong about 

that on so many levels. And I hope we will let them know more 

about this. 

And lastly, for our young people who are going to go to Brazil, 

where there are all these problems. I understand that they are 

spraying; they are doing everything, and I am very glad about that. 

There is a whole other issue of whether it is even morally responsible to have the Olympics. That is not our job to discuss, but it 

is happening. And we are now going to track our people voluntarily 

to see whether they get this disease, whether there is something 

amiss. I would just encourage us to reach out to these athletes very 

clearly. If the risk is so great that you are going to spend money 

following them, maybe they ought to know it. 

Senator RUBIO. Before I turn it over to Senator Isakson, are we 

providing our Olympic athletes a basic kit of repellent and whatever they need to take with them in order to prevent the disease, 

the contraceptives, whatever it is? What are we providing them? 

Are we working with the Olympic Committee to do so? 


FOREI-42327 with DISTILLER
26 

Dr. FRIEDEN. Yes. We are working with the Olympic Committee 

to provide both information and materials for the athletes for each 

of the different sports that are participating, each of the different 

associations. 

Senator RUBIO. Okay. 

Senator Isakson. 

Senator ISAKSON. Thank you, Senator Rubio. And thanks, to you 

and Senator Boxer, for calling this very important hearing. 

I want to issue an invitation to the four members that are here. 

In recent weeks, I have had the chance, with Dr. Frieden’s courtesy, to host two members of the United States Senate at CDC in 

Atlanta. And I would urge you to come down and spend an afternoon, and I will spend it with you, to see the research that is done 

and the reach that CDC has, particularly with regard to Zika. 

I want to underline, CDC is always referred to as the Center for 

Disease Control, but it is a five-word title, not a three-word title. 

It is Center for Disease Control and Prevention. And we are at a 

critical point on Zika, where we are—the prevention needs to be 

what we focus on, because controlling it does not do you any good 

once these cases start multiplying. 

I will give you some numbers for us to be aware of. The urgency 

of this matter is this: that, as of July the 6th, there are 1,133 Zika 

cases in the continental United States of America, and 320 are 

pregnant women, as of June the 30th. Is that about correct, Dr. 

Frieden? 

Dr. FRIEDEN. Yes. 

Senator ISAKSON. In the U.S. territories, there are 2,534 cases, 

and 279 are pregnant women. This is a crisis of major proportion, 

and we—time is of the essence. 

I have made two or three speeches on the floor, talking about the 

need for us to pass this. And it will be professional malpractice on 

our part if we leave here for 7 weeks and have not dealt with this, 

because Dr. Frieden and the Center for Disease Control and Prevention need the funds now to prevent what could be a major 

worldwide crisis, in terms of the Zika pregnancy. 

As a Georgian, just as an anecdotal piece of evidence, an employee of mine attended the briefing with Senator Collins that Dr. 

Frieden gave us on Zika a few months ago. His wife was in an 

early pregnancy. After the briefing, he moved his wife to Colorado, 

where these mosquitoes do not exist, just to be sure she is in a 

safer environment than Georgia during the term of her pregnancy. 

In our State, the two mosquitoes that are carrying the Zika both 

are indigenous to Georgia. 

So, this is something that is priority one, as far as I am concerned. And I think it is critical that we get it done now. 

I walked my dear friend Senator Boxer, whose passion I have 

seen illustrated on thousands of issues as we work together as cochairs of the Ethics Committee, but when you came in, you mentioned the Confederate flag. I want you to know that, as Chairman 

of the Veterans Committee, I saw to it that the Senate took out the 

House provisions, and there is nothing in the conference report at 

all that deals with the Confederate flag. Correct, Tim? 

Senator BOXER. That is not our understanding. 


FOREI-42327 with DISTILLER
27 

Senator ISAKSON. I see Tim nodding his head. I can tell you, I 

have the jurisdiction. I took care of that. 

Senator BOXER. Okay. Because I was just informed that it is in 

there, so let us go look at it. 

Senator ISAKSON. Well, as Chairman, I am telling you it is—if it 

is in there, somebody went over my head, because I am the one 

that made sure that Senate provision provided—prevailed, which 

was: No provision at all. 

Senator BOXER. In the military bill. 

Senator ISAKSON. Well, I am talking about the Zika bill we are 

talking about. It is not in there. 

Senator BOXER. Okay. I will double check. 

Senator ISAKSON. I appreciate it. 

Senator BOXER. I was just briefed today on that. 

Senator ISAKSON. But I want to underline the fact that this is 

about prevention. And we can have our differences on a lot of 

things, but we have got to do everything we can to get the resources in the hands of the CDC to develop a program of prevention. 

They demonstrated it on Ebola. The thing about Ebola that they 

get so much credit for, and should, is the Ebola outbreak took 

place, people developed Ebola, and they got out there and they 

treated people with Ebola. The number of deaths was minimized, 

but what people forget about is, the educational reach of CDC 

around the world to teach people best practices actually stopped 

the epidemic within a pretty unbelievable period of time. I think, 

about 13 to 16 weeks, if I am not mistaken. And that is what we 

want to see with Zika. We do not want to just deal with those that 

have it. We want to deal with those that do not have it, and make 

sure they do not get it. And this funding is absolutely critical for 

us to see to it that that happens. 

So, Senator Rubio, calling this hearing today and focusing on the 

need to do it is very important. And I hope, before we leave tomorrow, we can have an agreement in the Senate to ratify the conference report. 

And I want to thank all of you in healthcare for what you do to 

help protect the pregnant moms of America and the citizens of my 

State against what is a real threat. And the problem is, it is a delayed reaction. You find out today that they are pregnant; 9 

months from now, you find out if there is a problem. And 9 months 

from now is too late. We need to prevent every terrible pregnancy 

we can today, and that is why I want to focus on the need to pass 

this as quickly as possible in the United States Senate. 

I yield back. That was not a question. That was a speech, and 

I apologize. [Laughter.] 

Senator BOXER. It was a good one. 

Senator RUBIO. Senator Kaine. 

Senator KAINE. Thank you, Mr. Chair. And I am going to do 

some speeches and some questions. 

You know, this is such a serious problem, but this is also an illustration why a lot of people hate Congress. They hate Congress. 

And this is nothing bad on my Senate colleagues. We had some differences of opinion about this Zika, how to deal with it. And so, we 

voted on three different Zika provisions. There was a Democratic 


FOREI-42327 with DISTILLER
28 

provision to deal with Zika that did not get enough votes. There 

was a Republican provision about how to deal with Zika that did 

not get enough votes. And then there was a bipartisan provision 

about how to deal with Zika that did get enough votes. And there 

were some things in it that probably one side did not like, and 

some things that the other side did not like, but we got 68 votes. 

And it was a billion-one, not the number we might have liked, but 

we got it, and it was a clean bill. It was a bill about one thing: 

fighting Zika. That is what it was about. 

When it comes back to us, the bill is not about fighting Zika. 

Frankly, it is about fighting Planning Parenthood and paying for 

it by taking money out of the Affordable Care Act. So, we have got 

this massive public health challenge, and the American public is 

worried about it. And we are supposed to fight Zika. And that is 

what the Senate did. We fought Zika. But the bill comes back to 

us, and it is, ‘‘Let us fight Planned Parenthood. That is more important than fighting Zika. Let us take money out of the Affordable 

Care Act. That is more important than fighting Zika.’’ This is why 

people hate Congress. This is why people hate Washington. 

And again, this is no slight on us, because I think we actually 

reached the right compromise, but then the ‘‘fighting Zika bill’’ becomes the ‘‘fight Planned Parenthood bill’’ or the ‘‘fight the Affordable Care Act bill.’’ And it is my hope that we will get this thing 

straightened out. I know everybody here on this dais wants to. And 

I would second a point that Senator Boxer made in her comments. 

The right way to deal with this, probably down the road, is 

budgetarily to treat infectious diseases like we treat FEMA. We 

have a funding mechanism for FEMA. We do not know where a 

hurricane will hit. We do not know where there will be a forest fire, 

where there will be a flood. But we do know from experience that 

there will be these items, and so we budget for them and then we 

deal with them. 

We do not do that with respect to infectious diseases, and then 

that gives people the ability to play games and hold people hostage 

to try to ride their pet hobbyhorse instead of doing the thing that 

we are supposed to do. 

Couple of questions: I am curious, on the transmission. If you can 

be infected and asymptomatic, if you come back into the United 

States and you have been in an area where there is a lot of Zika, 

with respect to sexual transmission, you are telling males, for example, to use condoms. How long are you doing this? Is it for 

months? Is it for weeks? What is the advice that you are giving 

people when they return from Zika-infected areas? 

Dr. FRIEDEN. Our current advice, based on the best-available information, which we continue to accrue every day, is that, for men 

whose partners are pregnant, use a condom for the duration of 

pregnancy. Because we do not know how long that man may remain infectious. There are studies that are underway, but they will 

take 6, 12 months to finalize. 

Senator KAINE. What advice are you giving, if any, to men whose 

partners are not pregnant? 

Dr. FRIEDEN. For couples who are trying to conceive, our current 

advice is that, if they had no symptoms of Zika infection, they 

should wait at least 2 months after leaving the Zika area. And if 


FOREI-42327 with DISTILLER
29 

they did have symptoms, because they might have more virus with 

that, then it would be 6 months. 

Senator KAINE. Right. 

And then, here is another kind of transmission I was not aware 

of it until recently. If you are in a Zika-infected area and you come 

back to the United States, and you have been bitten by a mosquito 

there, and you may not have symptoms, your blood could have Zika 

infection. And so, if you are bitten by a mosquito in the United 

States, that could be a blood transmission to mosquitoes here. 

What are you—what advice are you giving people about needing to 

try to avoid mosquito bites in the United States after they return 

from a country that has a Zika problem? 

Dr. FRIEDEN. We encourage people to avoid mosquito bites by 

using DEET, staying indoors, staying in screened or air-conditioned 

spaces. But the scenario that you outlined is exactly the scenario 

that we think is most likely to spread Zika in parts of the U.S., 

where diseases like dengue have spread in the past, where we have 

seen clusters in parts of Florida and Texas through mosquito-borne 

transmission, although we have now shown that there is sexual 

transmission, and we know blood-transfusion transmission is possible if the blood is not screened, which is currently being screened 

in Puerto Rico and other places. 

The more likely way that it would spread in this country is the 

way it is spreading around the world, primarily, which is by mosquito bites. 

Senator KAINE. And so, if somebody returns to the United States 

from an area with a heavy Zika challenge, how long are you suggesting that it is important for that person to avoid getting bitten 

by a mosquito in the United States? 

Dr. FRIEDEN. Three weeks. 

Senator KAINE. Okay, thank you. 

I want to ask about the vector-control piece. And I know the FDA 

has a portion of that, as well. And so, I am assuming that, you 

know, you are all working together. The vaccine is going to take 

some time to develop. So, as I understand vector control, it is a 

number of different kinds of solutions. It is spraying and figuring 

out how to do spraying. I am—I understand that there is various 

proposals on the table for different—you know, mosquitoes that 

will not reproduce. And so, hopefully that could reduce the density 

of mosquitoes in certain areas. Talk about the range and kind of 

vector-control solutions that you are looking at. Recognizing that 

the vaccine is down the road, what can we do right now to reduce 

the density of mosquitoes that would be carrying this disease? 

Dr. FRIEDEN. So, these are very tough mosquitoes to control. 

They are referred to as ‘‘the cockroach of mosquitoes.’’ They live indoors and outdoors. They bite in the daytime and the evening. 

They readily develop resistance to insecticides. They have coevolved with people in urban areas, so they are an urban pest. 

The control measures, I would put into two large categories. One 

is proven safe and effective methods, but they have not been put 

together in a way that is effective to stop the mosquito. And we 

need to figure out how to use our existing tools better. And then 

new tools, experimental things like sterile male technology, where 

you release sterile males and try to crash the mosquito population. 


FOREI-42327 with DISTILLER
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Both of these things require more effort. We need to try the different methods out there and see how rapidly, how persistently we 

can reduce the mosquitoes. The recommended approach is an integrated vector-management approach, where you reduce standing 

water, you reduce larvae, and you use judiciously adulticides or 

pesticides to kill the adult mosquitoes. On a longer timeframe, 

more like the vaccine, or even longer than that, is the new tools. 

We need new insecticides, we need new ways to control mosquito 

populations. But we have to move forward rapidly in both of these 

areas. 

Senator KAINE. And could I just—my time is up, but one last 

question—or maybe two quick ones. 

On the—both of these—developing the vaccine takes a tremendous investment, but also the vector-control solutions, both to research to determine which are best, and then to deploy them broadly, that is also not cheap. That takes a significant investment, correct? 

Dr. FRIEDEN. That is correct. 

Senator KAINE. Those are all the questions I have. Thank you. 

Thanks, Mr. Chair. 

Senator RUBIO. Thank you. 

Senator Gardner. 

Senator GARDNER. Thank you, Mr. Chairman. 

And I apologize, I am not going to be able to use my full time 

here. That might not need an apology, but I am not going to be 

able to use it all. I have to go preside over—on the floor, here, soon. 

Dr. Frieden, I wanted to talk to you a little bit about the CDC 

work. Of course, Fort Collins, Colorado, is home to the Division for 

Vector-Borne Diseases and has done a tremendous amount of work 

at this location on vector-borne illnesses, such as Chikungunya, 

dengue, and Zika virus. And I was fortunate enough to have the 

opportunity to visit the work concerning Zika virus there at the 

laboratory in February of this year, including going in to look at 

the live mosquitoes, the larvae, and what was happening, and how 

the whole process worked. 

I learned, at this time, about a chemical called nootkatone that 

the CDC was working to reclassify as a biochemical pesticide active 

ingredient. Nootkatone is a—according to this tour, was a natural 

ingredient, I think, found in citrus, like grapefruit oil. It might be 

in some cedar trees, as well, but it has a natural grounding. Many 

may recognize this from their shampoos. I think this product is in 

many shampoos, as well. The EPA has to evaluate natural tick 

repellents and pesticides for registration before they may be sold 

for use by the public, to validate safety and efficacy. Has your 

agency—how have you coordinated with other agencies to expedite 

the approval of various products, nootkatone or others, to ensure 

they become available? 

Dr. FRIEDEN. Thank you very much, Senator. And we are delighted to—that you had the chance to visit our unit out in Fort 

Collins, Colorado. It is the lead unit for Zika and for this work. 

They do phenomenal work. Their innovation has been terrific. They 

have come up with the new and now increasingly available laboratory tests to diagnose Zika. They have also overseen the work in 


FOREI-42327 with DISTILLER
31 

our dengue branch, which has come up with some new means of 

capturing mosquitoes and tracking populations. 

The chemical you refer to, nootkatone, has been under evaluation 

for years at Fort Collins, and we have recently licensed it to several 

companies. We are working very closely with the EPA so that it 

could be brought to market as quickly as possible. It is food grade, 

generally recognized as safe, nontoxic, appears to be as effective as 

DEET against both mosquitoes and ticks. We are running out of 

different classes of insecticides. This appears to work in a totally 

new manner. So, we do not know, in the end, whether it will work 

out, but it is certainly very promising. We have had a good reaction 

from EPA that is willing to work with us and with the companies 

to get it to market as rapidly as possible. 

Similarly, with the diagnostic tests, we have had excellent collaboration with the Food and Drug Administration, which has, 

within days, approved for emergency use the diagnostic tests that 

we have developed. 

Senator GARDNER. Thank you. 

And I am going to have to go to the floor now. But are you familiar with the legislation that the Senate is considering from the 

House on the Zika funding? Are you familiar with the details of 

that legislation at all from the—the House-passed version of Zika 

funding? 

Dr. FRIEDEN. Yes. 

Senator GARDNER. Okay. And I would—because I hear people 

talk about the funding of Planned Parenthood. And I just want to 

make—I have a question for you on this funding. Does the House 

bill take money away from Planned Parenthood? 

Dr. FRIEDEN. I am not familiar with the exact funding allocations 

in that bill. 

Senator GARDNER. I believe the answer is no. And I would just— 

would love to—if you could get back to me on that. 

[The information requested had not been received at the time 

this document went to press.] 

Senator GARDNER. Thank you. 

Thank you. 

Senator RUBIO. Senator Kaine, you had a followup? 

Senator KAINE. Just one brief followup. Advice for all of us. Tell 

me if this is right. I understand that the mosquito that carries Zika 

breeds in containers, so not necessarily in standing water on the 

ground, necessarily, but more swimming pools or, you know, like 

the depression in the cover of my grill that ends up with rainwater 

on it, or a dog bowl in the backyard, a wheelbarrow. I have got one 

of those. I have got a canoe that gets water in it. So, one of the 

things that we can all do in our neighborhoods if we want to try 

to reduce the population density of this mosquito is to make sure 

that there is not water standing in containers in our yards and 

neighborhoods. Am I generally right about that? 

Dr. FRIEDEN. Yes, you are, Senator. And one of the challenges of 

controlling this mosquito is that it can breed in tiny amounts of 

water, the amount in a bottlecap. So, to eliminate standing water 

really means eliminating all standing water. And that is why it has 

been difficult to do it to an extent that you will actually see a large 

enough impact on the number of mosquitoes to make a difference. 


FOREI-42327 with DISTILLER
32 

But different communities are different. In one community, birdbaths were found to be one of the important sources of mosquitobreeding water. So, that is one reason why it is so important that 

communities in this country and around the world have the tools 

to track the numbers of mosquitoes and see if their mosquito-control activities are succeeding. 

Senator KAINE. Thank you. 

Senator RUBIO. The bigger question is, Why do you have a canoe? 

[Laughter.] 

Senator RUBIO. But we will get into that. 

Senator Markey. 

Senator MARKEY. Thank you, Mr. Chairman. 

Can I go to the pesticide issue and what breakthroughs we might 

be making in pesticides? Are there new pesticides that might be effective, that can supersede the need to use DEET or other pesticides? Can any of you talk about that? 

Dr. FRIEDEN. Thank you so much, Senator. 

First off, let us divide the different types of repellents in pesticides. So, DEET is a product that we would put on our skin. 

There are several FDA-approved products that are effective. I mentioned that there are some more products down the road which 

may be available in the future, that may be more pleasant to use, 

and just as safe and effective. There are also products that can be 

used in an area, what are referred to as spatial repellents, so 

things that you might burn in your household or spray in your 

household. There, we are trying to get better products available. 

And then third are materials that we would use to control mosquitoes in a community, so insecticides or pesticides. 

One of the really interesting things that has happened in recent 

years is the refinement of ultra-low-volume spraying, or ULV 

spraying. It uses tiny amounts of the pesticide, and a very different 

particle size, to penetrate more deeply, waft down more slowly, kill 

mosquitoes more effectively at a lower dose. And what we are seeing with those ultra-low-volume applications is the ability to control mosquitoes with less pesticide but more efficacy. 

So, one of the areas, again, is using our current tools more effectively, or tweaking them, if you will. The second is developing new 

tools, like new classes of insecticide. It has been decades since we 

have had a new class of insecticide available. That is why funding 

to develop new types of insecticides, ensure that they are safe and 

effective is so important. That is why we are so excited about the 

chemical that Senator Gardner mentioned, nootkatone, because it 

is nontoxic, food grade. And there are also new experimental methods, sterile male or gene drive, that are truly experimental, where 

we might be able to crash mosquito populations. We will have to 

see whether those are scalable, effective, and safe. But we will not 

know unless we study it. 

Senator MARKEY. Now, this ultra-low-volume insecticide, have 

you used it in Puerto Rico? 

Dr. FRIEDEN. That is currently under consideration. 

Senator MARKEY. And what would be the question that you 

would have to answer before its use? 

Dr. FRIEDEN. The spread of Zika is so rapid and so extensive in 

Puerto Rico that it is likely that, to have an impact, it would have 


FOREI-42327 with DISTILLER
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to be applied by fixed-wing aircraft or aerial spraying. That creates 

a lot of concern in Puerto Rico. And there has been very vocal concern about that raised. We think there is a gap of information, and 

we are working hard to get valid information out and to confront 

some myths about this. 

Senator MARKEY. So, your—the contention of the CDC or the 

U.S. Government is that this ultra-low-volume spraying can be 

done without any danger to human beings, but yet play a good role 

in helping to control the Zika fly? 

Dr. FRIEDEN. We believe it can rapidly reduce mosquitoes, and 

both CDC and the EPA have indicated that it can be done without 

risk to people, animals, or the environment. 

Senator MARKEY. Down in Puerto Rico right now, you are saying 

that is being resisted because of kind of a generalized fear that 

something can be done that harms other children, I suppose—— 

Dr. FRIEDEN. There are—— 

Senator MARKEY [continuing}. With those kinds of insecticides 

being put into the air. 

Dr. FRIEDEN. There are a number of concerns, a number of historical factors, current events, that make it a big challenge to do 

this there. But from a technical standpoint, we think this is the 

most likely way you could reduce the number of mosquitoes substantially and quickly. 

Senator MARKEY. Now, if an outbreak occurred within the continental United States, would this be one of the methods that you 

would recommend be used, let us say, in the first community that 

had an outbreak in order to try to isolate it quickly? 

Dr. FRIEDEN. It very much depends on the conditions in the community. But this is something that is done routinely in the U.S. In 

fact the State of Florida, each year, uses ULV aerial application in 

about 6 million acres. It is done routinely in Tampa, Miami, and 

other places. It is unfamiliar in Puerto Rico, and therefore, there 

are some concerns there. 

Senator MARKEY. Yeah. 

And can I take a—just a little bit of time just to talk about the 

cost of now treating children who have contracted microcephaly or 

other diseases related to this epidemic? The United States is now 

going to have long-term responsibility for the care of these children. And it is going to add millions, if not billions, of dollars over 

time to the budget of our country. And so, this is, to me, a classic 

example of where working smarter, putting the preventative tools 

in place up front will then protect us against huge, balloon costs 

that could last 30, 40, 50, 60 years with something that we could 

have prevented from exploding into huge numbers. So, even the 

children in Puerto Rico are Americans, and we have responsibility 

for them for years to come. So, not spending the money there now 

is something that ultimately we are going to pay a price that is 

hundreds of times higher in the long term, in terms of providing 

medical care for them. Could you talk a little bit about that? 

Dr. FRIEDEN. Our Birth Defect Center has documented that the 

care of one child with a severe birth defect can be up to $10 million, or more, in their lifetime. So, there is a personal tragedy, a 

family tragedy, but also an economic cost for not preventing preventable cases of birth defects. It is very rare to have birth defects 


FOREI-42327 with DISTILLER
34 

that can be prevented in the dozens, hundreds, or thousands. Our 

staff from our Birth Defect Center tell us that, in the 30 years they 

have been working on birth defects, this is the most urgent situation they have faced. 

Senator MARKEY. Yeah. So, you know, the old saying is ‘‘A stitch in time saves nine.’’ But here a billion dollars now could save $10 

billion later, because of all the children who would not ultimately 

be born with this disease, that we would have a moral responsibility, a legal responsibility, to take care of. 

So, I think that is something that we should all think about, in 

terms of Puerto Rico or any of the other places that could ultimately be affected by this disease, even if it is not something that 

happened inside the continental United States. 

Thank you, Mr. Chairman. 

Senator RUBIO. Thank you. 

I—as you know, I have supported the President’s request at 1.9 

billion. I thought we should err on the side of caution and do it as 

quickly as possible. I supported the 1.1, even if it was less, but it 

was something. I have been trying to urgently get us to do something to move funds so we can begin to address it. 

I was wondering if you could discuss—and perhaps this applies 

beyond simply the CDC—but what happens if, tomorrow, Congress 

adjourns for 6 weeks for the conventions and the summer and no 

funding is forthcoming? Where are the shortfalls? What will not be 

happening as a result of the inability to do something about this? 

Dr. FRIEDEN. Well, I will start, and my colleagues may want to 

say more. 

We will do the best we can, but this is no way to fight epidemics. 

It means we cannot begin the long-term projects to figure out how 

to protect women more effectively, to come up with better ways to 

diagnose Zika, to accelerate mosquito control strategies, because we 

have not been able to invest in those things. We also will not be 

able to repay the money we borrowed. We borrowed emergency 

money from States throughout the U.S. so that we could allocate 

it for Zika, not because that money was not important or needed, 

because that was the only money we had access to that we could 

use rapidly. And we have a gap in resources to fight Ebola in West 

Africa, because we had dollars that we had planned to use, starting 

October 1, to continue to keep Ebola in control in West Africa. We 

are continuing to see flares of the embers that are burning from 

the epidemic that is over there. 

And all of those resources are at risk. That is why passage of a 

supplemental is so important, and it shows us again why having 

some sort of an infectious disease rapid-response fund is critically 

important so that we do not have to go through this the next time 

there is a global public health emergency. Because, without a 

doubt, there will be a next time. 

Ms. KOEK. Yes, if I could—thank you very much, Senator—if I 

could just add to that and would certainly echo Dr. Frieden that 

we will do the best we can, but with the resources we have, we will 

be able to support the countries that I noted for a period of time, 

for several months during the next year, but we certainly will not 

be able to do very much to expand to other countries or really deepen the impact of our programs. It is enough to pay for activities 


FOREI-42327 with DISTILLER
35 

running through several months, but we cannot expand. And we do 

believe we need to expand. It cannot just be the five countries. 

Ambassador GARBER. Thank you very much, Mr. Chairman, for 

that question. 

It has impact for the State Department activities, as well. We 

hope to use the money from the supplemental for targeted support 

for U.S. citizens, such as repatriation loans for those that may be— 

U.S. citizens that may be affected, living overseas. As a former Ambassador, I can tell you, one thing that gives me great concern is 

that, if current trends of our medical evacuation of pregnant 

women as employees or their spouses in our posts overseas continue as—at the current rates, we do not have sufficient money for 

those medical evacuations throughout the year. This was part of 

the targeted money for that. And I think we have to take care of 

our own people. That is extremely important. And we are asking 

them to sacrifice by going overseas. We also hope to use some of 

that money for improving on communications plans in many countries and out to U.S. citizens. 

As we have heard in so much of the testimony today, getting the 

information out is so critical, and whether that is to U.S. citizens 

or help our embassies being able to help other governments get the 

information out—can do so much in the area of prevention. 

And also, last but certainly not least, it enables us to make contributions to international organizations, such as the World Health 

Organization. Countries look to the U.S. for leadership. If we are 

able to make those contributions, we know that it will stimulate 

other countries to do the same. 

Senator RUBIO. So, just to summarize, if this money does not 

happen tomorrow, then we are—we face a situation where all of 

the innovative work going into getting ahead of this will not be 

able to move forward. In addition to the risk of an Ebola or other 

outbreak happening somewhere in the world and the depletion of 

the emergency funds at the individual State level, we face the inability to fund the work we are doing with partner nations in the 

region who, if they are dramatically impacted, ultimately will impact us, because some of those cases will migrate here in search 

of medical care and so forth and on a humanitarian basis. 

And what I have heard from you, Secretary Garber, you are saying we may not even be—have—we will run out of funds to actually 

bring our people back home from being—who are deployed abroad, 

serving in our embassies and consulates around the world. 

Dr. Frieden, you talked about the screening of blood in Puerto 

Rico. Are we screening blood now in the mainland, as well? 

Dr. FRIEDEN. The Food and Drug Administration oversees blood 

screening in the U.S. There are parts of the U.S. that have undertaken screening. Other parts are waiting until they have local 

transmission or possible local transmission. Already, parts of Texas 

and elsewhere, where they have had dengue before, have screened. 

The screening tests are highly accurate in blood, so we want to ensure that we keep the risk as close to zero as possible. 

Senator RUBIO. Well, I ask—from the case of Florida, obviously 

Central Florida—all of Florida, in general, but Central Florida, in 

particular, has a very strong link with Puerto Rico, with the island. 

Do you know if Central Florida is screening its blood supply? 


FOREI-42327 with DISTILLER
36 

Dr. FRIEDEN. I would have to get back to you. 

[The information requested had not been received at the time 

this document went to press.] 

Dr. FRIEDEN. Also, already, the blood banks had, as of several 

months ago, begun a policy that people who have traveled to a 

place with Zika should defer donation. So, by deferring donors, that 

is an added layer of safety. So, people who have come from Puerto 

Rico, for example, would be told not to donate blood and would be 

asked specifically about that during that time. 

Senator RUBIO. Here is the last question, Dr. Frieden. If someone 

contracts Zika, in most of these cases they are not even symptomatic, in essence. There are people who are carrying it today in the 

United States that do not even know it, either because you are not 

symptomatic or, if you are symptomatic, you are largely going to 

present at an urgent care, emergency room, or a doctor’s office with 

what looks like the flu, in some cases, right? So, let us just use as 

an example if I were to contract Zika, the way I would manifest, 

if I had any symptoms at all, would very much mimic that of a 

viral infection or a flu, correct? 

Dr. FRIEDEN. Correct. 

Senator RUBIO. And the likelihood, even if I have traveled 

abroad, unless I reported it, or if I even showed up—because oftentimes I know these symptoms now, at 45 years of age. I have had 

the flu a number of times; I get the shot every year now, though, 

I have had the flu a number of times, and colds and what have you. 

And so, you would basically say, ‘‘I know what I have. I will just 

go through it.’’ The chances are that I may not even go to a doctor, 

much less be tested, because the—as I understand it, the screening 

for Zika is still not widely commercially available. It would require 

a referral to a Department of Health to look at it specifically. It is 

not the kind of thing you see in a panel written up in a doctor’s 

office. Is that correct? 

Dr. FRIEDEN. Yes, that is correct. 

Senator RUBIO. And so, the reality is that it is very much—it is 

quite possible, and perhaps, I would dare say, even probable, that 

there is already a mosquito infection that has occurred in the 

United States, and we just do not know it, because that person has 

not yet been tested. What we do not—what we know is, no one who 

has not traveled abroad and has not contracted it sexually has not 

tested positive yet. But we do not know if, somewhere in the 

United States right now, there is someone who contracted it from 

a mosquito bite in the United States, but because they are not 

pregnant or because they are not symptomatic or because they 

were not tested, because they just thought they had the flu, we do 

not know that it was transmitted by a mosquito. 

Dr. FRIEDEN. So, yes, it is certainly possible. Let me also say, on 

your blood donation question, I want to validate the answers I gave 

you before, and we will get you more information on that. But on 

testing, because, as you point out, 80 percent of people have no 

symptoms, those with symptoms have symptoms that are relatively 

mild, there is the possibility that transmission could occur without 

our recognizing it. That is why we are encouraging health departments throughout the U.S. to follow up on all known cases of Zika, 

and to encourage doctors in those areas where Zika might spread 


FOREI-42327 with DISTILLER
37 

through the local mosquito to be alert to the possibility, and also 

to test contact or family members who have illness to see if they 

have Zika. We have also been working hard to transfer our test 

methods to the private sector. They are not there yet, though we 

have made progress toward that. 

So, I think the scenario you outlined is certainly plausible. We 

anticipate that it will be very difficult to identify the first locally 

transmitted case of Zika. This is why we need better diagnostics. 

This is why we need better mosquito-control programs throughout 

the U.S. 

Senator RUBIO. Obviously, you cannot speculate entirely about 

the future, but do you have—personally, based on your expertise, 

do you have any doubt that we will see a mosquito transmission 

at the U.S.—in the mainland United States at some point? 

Dr. FRIEDEN. I think it is likely we will see mosquito-borne 

transmission. We do not have a crystal ball, but the best predictor 

is what has happened with dengue. And with dengue, we have seen 

clusters and isolated cases in various parts of the country, particularly Florida and also Texas. So, if—since Zika is spread by the 

same mosquito, we anticipate that the same type of pattern may 

occur, in addition to the unexpected sexual and, potentially, other 

means of transmission. 

Senator RUBIO. And my last question with regards to this is, 

Does it make any sense at any point in time, from a medical perspective, to add a test for Zika to the normal screening or the panel 

that would be administered to someone the way you would put 

some other infections or other diseases or other viral infections on 

a normal panel for a blood test? 

Dr. FRIEDEN. At this point, probably not, for a variety of reasons. 

If, in the future, we were to have a test for prior infection with 

Zika, that might give us some useful information. But we know 

that, if you have a test applied where the positivity rate is low, you 

will have a large number of false positives, even if the test is a 

good test. 

Senator RUBIO. There—I am sorry to—there is no—the only way 

to confirm a Zika diagnosis is through a blood test? 

Dr. FRIEDEN. Blood and urine. 

Senator RUBIO. So, it is—also appears in other fluids—— 

Dr. FRIEDEN. Yeah, there are two—broadly speaking, there are 

two types of tests for Zika, one that looks for the actual virus, the 

RNA of the virus. And that can be found in blood or urine for about 

the first 2 weeks, currently, after infection, or a test that checks 

for the body’s reaction to the virus, the antibodies, and that becomes positive within the first week or two, and generally stays 

positive only for about 8 to 12 weeks. 

Senator RUBIO. Yeah. And the reason why I ask only is because 

I was just wondering if, at some point, as part of the research that 

is being done, it is possible to create some sort of quick—painless, 

I suppose, if—ideally—a point-of-entry test that could be applied to 

travelers coming into the United States. But obviously, if it is your 

blood, you are asking them to submit to having blood drawn, which 

is—and having someone undergo a urinalysis at an airport is not 

the best way to welcome them to the United States. But—[Laughter.] 


FOREI-42327 with DISTILLER
38 

Dr. FRIEDEN. We have about 40 million trips to and from the 

U.S. to Zika-endemic areas, and perhaps 200 million—— 

Senator RUBIO. That is a lot of tests. 

Dr. FRIEDEN.—over land or other trips. The—theoretically speaking, if, a few years from now, we have a good test for prior infection, and a vaccine, you could imagine a situation in which travelers leaving the U.S. would want to find out if they had immunity, 

and, if not and potentially would become pregnant, get a vaccine. 

That is very theoretical. 

Senator RUBIO. We have run long, so my last question—I promise this is the last question. 

If someone has traveled abroad to one of these countries where 

Zika is present, and they have either had relations or have been 

bitten by a mosquito, or think they might have been, what—how 

can they—how would they get tested? Could their doctor order a 

test? 

Dr. FRIEDEN. Any doctor in the U.S. can contact their local 

health department. We have already distributed our test, and 

trained and supervised labs around the country, so that most State 

health labs already can do this test. And those that do not can send 

it to CDC labs to have done. So, again, in the first 2 weeks, there 

is one type of test; from 2 to 12 weeks, another type of test. If people, particularly pregnant women, are concerned that they may 

have an infection, they should be tested. And people with symptoms of Zika who have traveled should also be tested. And those 

tests are available. 

As you indicate, if we could get them into the private sector, they 

would be more widely available. And we are doing that as rapidly 

as possible. We actually got Food and Drug Administration approval to do that, within the past week. We have already shipped 

the materials to private labs, and they are now undergoing the validation so that they can be comfortable in doing this and providing 

the results. 

Senator RUBIO. Well, I want to thank all three of you for your 

time and for being here. And, from the attendance today, obviously, 

on the subcommittee there is clearly an interest, both among our 

members and the general public. 

Before we conclude, I would like to include a study conducted by 

the University of Florida, the finest learning institution in the 

Southeast United States—[Laughter.] 

Senator RUBIO.—from Dr. Glen Morris, as part of the hearing 

record. That was a point of personal privilege. 

[The information referred to can be found in the ‘‘Additional Material Submitted for the Record’’ section at the end of this document.] 

Senator RUBIO. And the record for this hearing was going to remain open until the close of business on Friday. 

And, with that, the meeting is adjourned. 

[Whereupon, at 4:15 p.m., the hearing was adjourned.] 


FOREI-42327 with DISTILLER
(39) 

Additional Material Submitted for the Record 


FOREI-42327 with DISTILLER
40 

ZIKA VIRUS EXPLAINED

February 19, 2016 

EMERGING PATHOGENS INSTITUTE

UNIVERSITY OF FLORIDA


FOREI-42327 with DISTILLERZika-1.eps

FOREI-42327 with DISTILLER

• Dr. Amy Vittor, MD, Infectious Diseases 

specialist, UF College of Medicine and 

UF Health 

• Dr. Michael Weiss, MD, Neonatologist, UF 

College of Medicine and UF Health 

• Dr. John Lednicky, PhD, virologist, UF College of 

Public Health and Health Professions 

UF I Emerging Pathogens Institute UNIVERSITY of FLORIDA 

• Dr. Jorge Rey, PhD, Interim Director, UF Flo

Medical Entomology Laboratory 

• Dr. Danielle Stanek, DVM, Zoonotic and Vec

borne Disease Program Manager, Florida 

Department of Health Division of Disease 

Control and Health Protection 

• Dr. Glenn Morris, MD, Infectious Diseases 

specialist and Director, UF Emerging Pathog

Institute 

FOREI-42327 with DISTILLER

Amy Vittor, MD, PhD 

Assistant Professor of Medicine 

College of Medicine 

University of Florida 

UF I Emerging Pathogens Institute UNIVERSITY of FLORIDA 

FOREI-42327 with DISTILLER

Where did Zika virus come from? 

Legend 

e sampling 

Contours 

-- Tarmac road 

•· ·· ·• Motorable Track 

QzikaForest 

"", ', Forest 

Wedand 

N 

W-<?-E 

s 

FOREI-42327 with DISTILLER

How the Zika virus spread around the world 

Pacific Islands (New Caledonia, L__________/ French Polynesia 

Cook lslands, Easter 

.sourctd . .ancnttiUoiver..•ty, JoUtn11l of Virology ®OW 

FOREI-42327 with DISTILLER

How is Zika virus spread? 

Primary route 

of transmission 

Humans 

© 2007 Nature Publishing Group Adapted from Whitehead, S. S. eta/. 

Prospects for a dengue virus vaccine. Nature Reviews Microbiology 5, 

518- 528 (2007). All rights reserved. 

Secondary routes of transmission 

(extent of contribution to overall 

transmission unknown) 

Semen 

Urine 

Saliva 

FOREI-42327 with DISTILLER

Zika Symptoms 

• 80% of people who are infected do not have any symptoms at all 

• 20% who have symptoms are sick for 2-7 days, and have fever, rash, joint 

pains, red eyes, muscle pain and/or head ache 

• No specific therapies exist 

• No vaccine available, but development underway by Sanofi Pasteur, 

lnovio, Bharat Biotech {at least 18 months away from large scale trials) 

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Guilla in-Barre Syndrome 

• Neurological condition causing muscle weakness an

possibly paralysis 

• In severe cases, patients need ICU care to support 

breathing 

• Guillain-Barre syndrome is seen following numerous 

types of infections, and is due to our own immune 

response that damages neurons 

• Spikes in cases of Guillain-Barre have been seen in 

Polynesia, Brazil, El Salvador and Colombia following 

the arrival of Zika virus 

• Whether Zika virus causes Guillain-Barre syndrome 

not yet known 

FOREI-42327 with DISTILLER

Microcephaly 

• A condition in which an infant's head is smaller than 

expected, caused by infection, toxins, or genetic disorders 

• 20-fold increase seen in microcephaly in Brazil late 2015 

• Zika virus has been found in the brain tissue of some 

deceased infants and in amniotic fluid 

• Babies with microcephaly in Brazil have additional brain 

damage that is consistent with an infectious cause 

• Greatest risk appears to be associated with infection 

during first trimester 

• Insecticide exposure is not likely to have caused the 

increase in microcephaly. Pyriproxyfen, the larvicide in 

question, has not been associated with fetal abnormalities 

in animals. 

• Rigorous epidemiological and laboratory studies are 

needed to establish causation 

FOREI-42327 with DISTILLER

Michael Weiss, MD 

Associate Professor in the De_partment of Pediatrics -Neonatology Division 

College of Medicine 

University of Florida 

UF I Emerging Pathogens Institute UNIVERSITY of FLORIDA 

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M ICROCEPHALY 

•Michael D. Weiss, MD I Associate Professor, Department of Pediatrics 

UFI:FioRmA. 

FOREI-42327 with DISTILLER

What is Microcephaly? 

• Clinical finding of a small head when compared to infants 

of same sex and age. 

• Usually less than the 3 Percentile. 

• Not a diagnosis 

• When present at birth called congenital microcephaly. 

Baby with Microcephaly 

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FOREI-42327 with DISTILLER

Causes of Microcephaly 

• Primary due to abnormal development 

• Genetic Etiology 

• Secondary due to arrest or destruction of normally 

formed or forming brain. 

• Vascular • Teratogenic • Infection 

• Cytomegalovirus (CMV) 

• Toxoplasmosis Gondii • Rubella (German Measles) • Zika 
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FOREI-42327 with DISTILLER

John Lednicky, PhD 

Associate Professor and Co-Chair 

Environmental and Global Health College 

of Public Health and Health Professions 

University of Florida 

UF I Emerging Pathogens Institute UNIVERSITY of FLORIDA 

FOREI-42327 with DISTILLER

Zika virus: Some basic information 

Zika virus (ZIKV) is a type of 

flavivirus that is mosquitoborne. 

ZIKV is highly related to Yellow 

Fever, Dengue and West Nile 

viruses. 

ZIKV particles are about 40 nm 

in diameter and thus cannot 

be seen using a regular 

microscope (a transmission 

electron microscope [TEM] is 

usually used to visualize 

them). 

Mprotein 

le RNA 

... TEM 

T =3·11ke organization 

of surface dlmers ~ 

,, j Zika virus 

MptDM'tn 

West Nile virus 

T• 3 Capsid 

FOREI-42327 with DISTILLER

Virus Detection 

Centrifuge to pellet blood cells 

Whole Blood+ EOTA 

Transfer plasma to storage tube 

and freeze at 

Virus isolation / 

nucleic acids 

• Virus discovery • Signal amplification 

6 cell lines 

incubation temperatures 

+serum, - serum in cell media +trypsin, -trypsin in cell media 

Requires extensive training 

Biocontainment an issue 

Virus 10 costs can be high 

RT -PCR/PCR-based detection 

Usually a targeted approach 

-Specific PCR primers 

-Universal primers 

Real-time RT-PCR Detection of Dengue virus-1 RNA 

FOREI-42327 with DISTILLER

Chikungunya and Dengue Fevers 

Occurred in Haiti in 2014- 2015 

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FOREI-42327 with DISTILLER

Timelines 

• The EPI detected ZIKV in May 2015 from Haitian 

blood collected in Dec. 2014. 

• March 26, 2015- ZIKV infections confirmed in Brazilians 

with 

dengue-like 

iII nesses. http:/ ;wwwnc.cdc.gov/eid/a rti cle/21/10/1s-os47 _article 

• Jan. 14, 2016- News media report outbreak of Zika Fever in Haiti. 

• Jan. 23, 2016- Dominican Republic reports cases of 

ZIKV infections. 

LLC-MK2 cells (Negative) LLC-MK2 cells+ 

ZIKV 

FOREI-42327 with DISTILLER

Identification of Zika virus 

Nuclease (degrades Extract 

nucleic acids not > vRNA/vDNA 

within virions) 

Virus ID 

Random primers 

< Sequence amplicons 

• Primer walking approach 

• 5' and 3' RACE (Rapid amplification of 5' and 3' comp lementary ends) 

FOREI-42327 with DISTILLER

RACE Structural Non srrucrural 

s·.J c JX'-" E NSl NS2A NS2B I NS3 NS4A NS4B NSS } --l' 

T Envelop<> Protcas<' woth NS2B RNA polymerase 

ME.'n1blane pr&ui'SOI t1rhcf1Sf Me;hy\tran\fera5e 

Caps'd 

• 5' is capped by a 5'-type 1 structure (m7G5'ppp5'A) and that must 

be removed 

• 3' is not polyadenylated 

• RNA ligase-mediated RACE is used 

5' RLM·RACE 

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V =A, C, orG 

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Genetic analyses indicate that ZIKV Haiti predates 2015 Brazil strains 

* 

* 

o.oos 

FOREI-42327 with DISTILLER

Jorge Rey, PhD 

Interim Director of the Florida 

Medical Entomology Laboratory 

University of Florida- IFAS 

UF I Emerging Pathogens Institute UNIVERSITY of FLORIDA 

FOREI-42327 with DISTILLER

Mosquito Vectors in Florida 

Aedes aegypti 

& 

Aedes albopictus 

Yellow fever mos

African origin 

Invaded 13-141h C

Asian Tiger Mosq

Asian origin 

Invaded 1980s 
66 


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FOREI-42327 with DISTILLERZika-28.eps

FOREI-42327 with DISTILLER

Container mosquito management 

• Chemical (adulticiding) 

• pyreth roids 

• malathion 

• naled 

• Biological 

• Sterile males • Gm mosquitoes 

• Wolbachia 

Source reduction 

Insect growth regulators (methop

Bti 

Predators 

FOREI-42327 with DISTILLER

PREVENTION 

Remove, cover, or flush water-holding 

containers from around the home. 

Apply an EPA-approved 

repellent according 

to label instructions. 

Wear protective clothing when expo

to mosquitoes 

FOREI-42327 with DISTILLER

Danielle Stanek, DVM 

Zoonotic and Vector-borne Disease 

Program Manager 

Florida Department of Health- Division o

Disease Control and Health Protection 

UF I Emerging Pathogens Institute UNIVERSITY of FLORIDA 

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Current Status (2/18/2016) 

• To date no cases of locally 

acquired Zika fever have been 

reported 

• 24 Zika fever cases (travelassociated) acquired outside 

the US 

• 9 counties with imported 

cases: Alachua (1), Brevard 

(1), Broward (4), Hillsborough 

(3), Lee (3), Miami-Dade (9), 

Osceola (1), Saint Johns (1) 

and Santa Rosa (1) 

c=J Nocases 

[=:il Cases 

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DOH Response Partners 

• State Arbovirus Task Force 

• Mosquito control representatives 

• State agencies • Universities 

• Targeted messaging to health care providers 

• Hospitals • American Congress of Obstetricians and Gynecologist

• Midwives/nurses 

• Working with internal partners 

• Birth Defects Registry • Maternal and Child Health • Public Health Tracking 

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DOH Response Activities 

• Response similar to dengue/chikungunya 

• During interview 

• Complete travel history • Avoid mosquito bites while ill 

• Highlight prevention methods 

• Inform local mosquito control officials of suspect 

cases 

• Provide testing for health care providers 

• Provide public information on disease, 

transmission, prevention, protective actions 

• Updated information on public web page 

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Suspected Zika Fever Case Investigatio

Sick person 

Health care 

provider Laboratory 

Interview 

Case reported 

County 

Health 

Department 

Department of 

Health I State Office • Alerts/advisories 

• Testing Approval 

•Subject Matter Experts 

•Policy Guidance 

C

DC 

Mosquito 

Control 

•Case Consultation 

•Weekly reports •Publish statewide data • Publish nationwide data 

Stat e 

Laboratory 

Response 

Public 

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DOH Successful Response Model 

• Key partnership with local mosquito control districts 

• DOH notifies mosquito control upon suspicion of mosquito-bo

illness 

• Appropriate mosquito control measures are implemented 

• Successful partnership demonstrated previously 

• Chikungunya 2014 

• 510 imported cases identified 

• 12 sporadic local cases 

• Coordinated DOH- Local mosquito control activities 

• No sustained local transmission 

FOREI-42327 with DISTILLER

t. 

USE REPELENTE PARA 

INSECTOS OUE 

CONTENGA UNO' DE LOS 

SIGUIENTES 

INGREDIENTES ACTIVOS 

DEET 

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EN 
77 

STATEMENT SUBMITTED BY THE CENTER FOR VACCINES AND

IMMUNOLOGY AT THE UNIVERSITY OF GEORGIA

During the last week of June, 2016, the first person in the continental United 

States died in Utah from Zika virus infection. Zika is almost never fatal, however, 

an elderly Puerto Rican man also died in April from Zika virus complications. Urgent action is needed to stem the spread of Zika virus in the United States and 

throughout the Americas. Before 2007, very few human cases of ZIKV infection were 

reported, but now there is a full-blown epidemic and the beginnings of a ZIKV pandemic. On February 1, 2016, the World Health Organization declared the virulent 

Zika virus an international health emergency. Zika virus is spreading explosively 

and could affect millions people in the United States in the next year. This mosquito-transmitted virus is linked with birth defects in thousands of babies in the 

Americas, as well as Guillain-Barre syndrome, a disorder in which the immune system attacks the nervous system. Pregnant women are a high risk of complications 

following Zika infection. 

Currently, there is no approved vaccine against the Zika virus (ZIKV). However, 

several organizations, including the University of Georgia (UGA), are actively developing vaccines using various platforms and technologies. While many of these are 

in the early stages, several are based upon previously approved platforms and designs against dengue virus and other infectious disease agents. To address this challenge, the University of Georgia and metro Atlanta-based GeoVax have entered into 

a partnership to develop and test a potential Zika virus vaccine. Dr. Ted M. Ross, 

director of UGA’s Center for Vaccines and Immunology and Georgia Research Alliance Eminent Scholar, is leading a team of UGA researchers to develop this novel 

Zika virus vaccine. GeoVax’s novel vaccine platform technology takes a different approach with virus-like particle (VLPs) by using recombinant DNA or viruses to 

produce VLPs in the person being vaccinated so they more closely resemble the 

virus generated in a body during a natural infection. GeoVax’s platform is focused 

on vaccines against HIV and hemorrhagic fever viruses, including Ebola. It is also 

being evaluated for use in cancer vaccines. The UGA research team focuses on designing, developing and testing vaccines, including those for VLPs, which mimic a 

live virus but don’t contain genetic material and cannot replicate or cause infection. 

VLPs give immune systems a ‘‘head start’’ in fighting infection, Dr. Ross said in a 

statement. 

We strongly encourage the U.S. Congress to pass comprehensive Zika legislation 

for research. 

TED M. ROSS, PH.D. 

Director, UGA Center for Vaccines and Immunology 

Æ 


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