Guest Host: Lisa Desjardins

Mira Trujillo (L) picks up bug repellent from Brunilda Mendez (C) and Rachel Romano who have a table setup to help people prevent getting the Zika virus in a building located in the Wynwood neighborhood where the Zika virus has broken out on August 4 in Miami, Florida.

Mira Trujillo (L) picks up bug repellent from Brunilda Mendez (C) and Rachel Romano who have a table setup to help people prevent getting the Zika virus in a building located in the Wynwood neighborhood where the Zika virus has broken out on August 4 in Miami, Florida.

The Centers for Disease Control’s travel warning for the Zika virus expanded four days ago — to another neighborhood of Miami. And experts say the virus likely isn’t done spreading. Most at risk: Gulf coast areas like Louisiana, still overrun by standing water after historic flooding, and Texas, vulnerable to infected mosquitoes because of its hot climate. Zika’s threat has ignited conversations for families who are pregnant and those who hope to become pregnant, including a new debate around reproductive healthcare and abortion. Meanwhile, new vaccines are moving through early-stage trials at a rapid pace, but how quickly they come to market could hinge on funding woes in congress. Where Zika is headed — and how we’re treating it.

Guests

  • Dr. Anthony Fauci Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health
  • Dr. Kavita Patel Fellow, Brookings Institution Center for Health Policy; primary care physician at Johns Hopkins Medicine; founder, Tuple Health, which works to improve communication with patients
  • Arthur Caplan Director, division of medical ethics, New York University Langone Medical Center
  • Dina Fine Maron Associate editor for medicine, health and biology, Scientific American
  • Arian Campo-Flores Staff reporter, The Wall Street Journal

Transcript

  • 10:06:54

    MS. LISA DESJARDINSThanks for joining us. I'm Lisa Desjardins filling in for Diane Rehm. She's on a station visit to WUNC in Raleigh Durham. This week, health officials are warning that the Zika virus could spread from Florida to other Gulf states. But when, how quickly and will we find a cure. Doctors and patients are struggling with how to deal with pregnancies affected by the virus as researchers race to find a cure.

  • 10:07:20

    MS. LISA DESJARDINSJoining me now in studio to talk about all of these challenges is Dr. Kavita Patel. She's a primary care physician at Johns Hopkins Medicine and a fellow at the Brookings Institution Center for Health Policy. And Dina Fine Maron, associate editor for medicine, health and biology at Scientific American. From New York, we have Arthur Caplan, the director of the division of medical ethics at New York University's Langone Medical Center.

  • 10:07:45

    MS. LISA DESJARDINSAnd from Miami, Arian Campos-Flores, a reporter with The Wall Street Journal. But first, we're going to Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health for an update. Thank you so much for being with us, Dr. Fauci. I want to...

  • 10:08:04

    DR. ANTHONY FAUCIGreat to be with you.

  • 10:08:05

    DESJARDINSThank you. I want to start by asking you to give us a picture of Zika across the country right now. How many cases are we seeing and where and by how much is the disease spreading?

  • 10:08:17

    FAUCIWell, we want to make sure that people understand the difference between a travel-related case and a locally-acquired case. In the United States right now, we have over 2,000 people scattered throughout the country, almost 500 of whom of which are in Florida who have acquired Zika elsewhere, very likely South America, Central America or the Caribbean, and have come to the United States. The issue that we're facing now is that when you have the mosquitoes, namely the aedes egypti that are very capable of transmitting and are the primary vectors of this infection, we have them in the United States, particularly concentrated around the semi-tropical areas of the Gulf Coast states.

  • 10:09:05

    FAUCIAnd in that regard, what we've seen is something that we actually were able to predict months ago. And that is, when you have travel related cases like we have densely in Florida and you have a lot of mosquitoes, sooner or later you're going to have what's called a local transmitted case. And that means someone who was infected elsewhere, is in the United States continental, gets bit by a mosquito and them bites someone who has never left the continental United States. That's what's called a locally acquired case.

  • 10:09:35

    FAUCIIf you look at the locally acquired cases, plus the sexually-transmitted cases, in the United States, what we have right now are 37. It was 36 originally, but Florida just reported an additional one. 37 locally acquired cases in Florida fundamentally concentrated on two very restricted areas, not exclusively, but mostly. One is in the Winwood area, which is a one-square mile area north of Miami. And the other is the South Beach section of Miami Beach, which is about a 1.5 square mile area.

  • 10:10:11

    FAUCISo that's that picture. A lot of travel-related cases and right now, individual and small clusters of locally transmitted cases.

  • 10:10:18

    DESJARDINSAnd Dr. Fauci, am I correct that that first sort of set of locally transmitted diseases in the Winwood area of Florida, there may be some relative good news that we really haven't seen the cases there expand in a couple of weeks. There hasn't been new cases in Winwood. There has been a new area of Miami where we've seen cases. Is that correct?

  • 10:10:37

    FAUCIRight. That is correct. And the reason for that is very likely that there has been what we have in a (word?) is really the only immediate way to contain this and that is very aggressive mosquito control. And when you're talking about what do you do about these outbreaks to prevent them from becoming sustained and from becoming disseminated, it's fundamentally based on mosquito control. And there are a few ways to do that.

  • 10:11:03

    FAUCIYou clean up the environment and get rid of standing water, even in places that are inconspicuous, places as small as a bottle cap and as a large as a little pool of standing water. And then, you do what the authorities in Florida have been doing. You try to kill the larvae in the adults by a variety of spraying, either backpack spraying, truck spraying, or even they resorted to aerial spraying. That's probably the reason why we have seen no further spread.

  • 10:11:30

    FAUCIBut having said that, we have a caveat that I would not be surprised if, in fact, we do see additional cases in Florida because these mosquitoes are very, very difficult to completely suppress. You think you suppress them one day and then two days later, they're back to their full density.

  • 10:11:46

    DESJARDINSWell, let's talk about vaccines because as it seems, this is a difficult to contain disease and these mosquitoes, in particular, are difficult to kill. Tell us about where we are with the vaccines. I know there are two vaccines in phase one trials right, but that things are moving rather rapidly. And one of those funded by NIH.

  • 10:12:05

    FAUCIThat's correct. So when you think about vaccines, the ones that go first into human trials, which we call phase one, that's not necessarily the best one. We have about a half a dozen candidates that are in various stages. The ones you just mentioned correctly have gone into human trial. The NIH candidate we started phase one trial on August the 2nd here in the Bethesda area outside of Washington. It is also going to be tested at Emery and Atlanta and at the University of Maryland of Baltimore.

  • 10:12:35

    FAUCIThere'll be 80 individuals in that trial. That's a small number because it's a phase one trial. The only question you're asking, is it safe and does it induce the kind of response that you would predict would be protective? We're going to get that answer around November/December. And then, if, in fact, all systems are go, we'll move into a much larger efficacy trial, one to ask the question does it actually work. And that'll involve anywhere from 2400 people to 5,000 people in a number of sites in which there is active outbreak.

  • 10:13:07

    FAUCIThat, hopefully, and I'm pretty confident it will start -- if we get the resources to do it, it'll start somewhere in the beginning of 2017.

  • 10:13:17

    DESJARDINSSo we're still -- even though this is a fast move for a vaccine, it's still going to take many months before a vaccine could be available.

  • 10:13:26

    FAUCIOh, absolutely. In fact, I mean, if you look at it, the thing that determines how quickly you get a vaccine is related to two issues. One, how inherently effective the vaccine is, does it work really well? The better it is, the quicker you know of it. And the other is the number of cases. If you're testing a vaccine in the middle of an outbreak, you have a much quicker way to get to the end game. If you're dealing with infections that get suppressed by good public health measures, it may take several years.

  • 10:13:55

    FAUCIThe earliest we predict that we'll have it available, the earliest if all things go well, will be in the beginning or middle of 2018. So that gets back to what you said. The immediate approach to this right now is clearly mosquito control.

  • 10:14:10

    DESJARDINSOkay. One other question I have about the mosquito control specifically. The temperature in Miami today is expected to get to 90 degrees, about 80 degrees today in New York. We're at the height of summer. Fall is coming. To some extent, for much of the United States, this may be a race against time as temperatures get low enough for the mosquito population to just die naturally. But how low does the temperature need to get for the weather itself to control mosquitoes?

  • 10:14:36

    DESJARDINSAnd is that every something that will happen in the southern part of the United States, Louisiana, Florida?

  • 10:14:41

    FAUCIWhen you have -- that's a very good question. When you have semi-tropical conditions as we have along the Gulf Coast, it's essentially a year-round thing where there are some mosquitoes. What changes, Lisa, is the density of the mosquitoes. When you have wintery conditions like you have in the northeast where you have freezing temperatures, you certainly are not going to have mosquitoes. Sometimes eggs can survive over winter. Sometimes not.

  • 10:15:07

    FAUCIBut you're thinking more in terms of controlling the density rather than getting rid of mosquitoes completely because that's a fool's errand in areas that are semi-tropical. You try to keep the density down low enough so that you decrease, greatly, the odds of there being ongoing transmission.

  • 10:15:25

    DESJARDINSAnd Dr. Fauci, we have with us today Dr. Kavita Patel who has a question from one of her patients for you.

  • 10:15:31

    DR. KAVITA PATELHi, Dr. Fauci. So a common question from patients is the ability to receive a rapid test for the Zika virus. And obviously those tests have been developed, are in development and yet, a lot of patients have questions about the generalized availability. Do you have a comment on that availability?

  • 10:15:53

    FAUCIYeah, that's a very good question. And if you're talking about a test for the virus itself, as you well know, people sometimes, and understandably, get confused. If you're asking the question, am I infected now, that's a molecular PCR test that you do in the blood or in the urine.

  • 10:16:11

    DESJARDINSAnd can you -- PCR for listeners?

  • 10:16:11

    FAUCIYeah, it's a preliminarized chain reaction which is ability to detect very minute amounts of nucleic acids of which the virus is made of. So you can tell if you're actively infected. That is a test that's readily available, most labs have it. You get into trouble when people want to know was I infected two, three months ago. That's a test that isn't as widely available. It used to be only very restricted areas, like the CDC. It's becoming more available, but it isn't easily available where you can walk into a doctor's office and get it.

  • 10:16:48

    FAUCIThe trouble with that test is that it has a degree of non specificity to it. In other words, whereas the molecular test can tell you are you definitely infected or not with Zika, the antibody test can cross react with other similar viruses like dengue or vaccination to yellow fever. So that's when things get soft as it were about definitive diagnoses.

  • 10:17:11

    DESJARDINSAnd this is why it's important for people to be -- to err far on the side of caution if they think they were in a zone where they could've been infected. To take those, I think, eight weeks for a women, longer for a man, before they try to get pregnant if they're not pregnant currently.

  • 10:17:25

    FAUCIAbsolutely. And that’s the reason why -- I mean, if you look at the CDC recommendations, and I really encourage people to do that, to go to the CDC website and do that, all of what you're talking about is there.

  • 10:17:36

    DESJARDINSOkay, excellent. That's Dr. Anthony Fauci. Thank you so much for joining us, sir. We're going to let you get back to your very important work. We thank you for joining us and for being such a friend of the show.

  • 10:17:44

    FAUCIGood to be with you. Thank you.

  • 10:17:45

    DESJARDINSAll right. We're going to take a quick break now, but coming up, we're going to talk more about Zika detection, Zika prevention and also, something that you may not hear a lot about, but the ethics of Zika, the discussions that it's bringing out now. I'm Lisa Desjardins and we'll be right back.

  • 10:20:02

    DESJARDINSAnd welcome back. I'm Lisa Desjardins sitting in for Diane Rehm. We're talking about the Zika virus today, where it stands, how prevention efforts are going, and also what's ahead. You are part of this conversation. We want to hear from you. Give us a call at 1-800-433-8850. Send us email at drshow@wamu.org. Or join us on Facebook or Twitter. We love your tweets. This is obviously an important topic that is on the minds of almost every American, so we want to hear from you.

  • 10:20:31

    DESJARDINSAnd we just got this email from Hugh McGovern. He writes, I'm a medical student in the West Indies. Just yesterday, we saw a young man who had been hospitalized for 20 days with Guillain-Barre syndrome, after having been infected with Zika. Can your panel speak to the increased risk of GBS associated with Zika and the potential impact. I'm going to go to you, Dr. Kavita Patel, to talk about what we know about the effects of Zika. We're still learning about when it affects fetuses, are we not, and how it affects humans.

  • 10:21:03

    PATELCorrect. So the questioner asked about a male and...

  • 10:21:07

    DESJARDINSRight.

  • 10:21:07

    PATEL...this syndrome, Guillain-Barre kind of syndrome is -- it represents something that can happen after many different types of viruses, so it's not just related to the Zika virus.

  • 10:21:16

    DESJARDINSHmm.

  • 10:21:17

    PATELBut it's basically a description of losing your nervous function in a rapid manner. And it can be the effect of a viral infection. The most common symptoms that patients who actually present with symptoms -- remember, the majority of people do not present with any active symptoms of the Zika virus. So when people present, like this questioner asked, it's actually very unusual.

  • 10:21:40

    DESJARDINSHmm.

  • 10:21:41

    PATELOther more common symptoms include myalgias or muscle pain, muscle aches and pains...

  • 10:21:46

    DESJARDINSOr the rash we see this sort of like red bumps.

  • 10:21:47

    PATEL...a rash, fever.

  • 10:21:49

    DESJARDINSRight.

  • 10:21:49

    PATELCorrect. So unfortunately that's so nonspecific that we really can't say, well, if you have this, then you have Zika.

  • 10:21:55

    DESJARDINSI know you had patients send you photos of their mosquito bites.

  • 10:21:57

    PATELI do. I still -- I have a lot of people who are worried that maybe their mosquito bite looks like you can tell if it's a Zika-related bite. Unfortunately, we can't.

  • 10:22:07

    DESJARDINSHmm.

  • 10:22:07

    PATELI think with respect to pregnant women, something that's really critical to remember is that we're still learning and researchers are trying to do as much as they can to identify the effects on the fetus as early as possible. But what we're understanding is that it still takes potentially until 20 weeks or later to see the descriptions and the ultrasound evidence of that microcephaly or small head size. We do think that between 16 to 20 to 24 weeks, you can see a decrease in the growth rate of a fetuses head and that that can be one of the first signs that that's an active...

  • 10:22:44

    DESJARDINSThat something's off, right.

  • 10:22:45

    PATELCorrect. So unfortunately, a pregnant mother might not have any active symptoms, which is, again, I think Dr. Fauci echoed the recommendations from the CDC for pregnant women. And then never forget that partners of pregnant women can also potentially transmit the virus. So this doesn't just affect the pregnant woman. It's really about the pregnant woman and potentially any other sexual partners as well.

  • 10:23:08

    DESJARDINSAnd one more not on this, Dr. Patel, you know, at one point there was hope that perhaps -- the most vulnerable time for a pregnant woman was that first trimester. But now it's not clear, even if a baby is born without microcephaly...

  • 10:23:23

    PATELCorrect.

  • 10:23:24

    DESJARDINS...that there may be other developmental disorders...

  • 10:23:26

    PATELCorrect.

  • 10:23:26

    DESJARDINS...that can happen later in pregnancy because of Zika.

  • 10:23:29

    PATELRight. And Puerto Rico, which is one of the most affected areas -- a U.S. territory, obviously -- has actually set up a surveillance system that goes up until I believe it's the age of three years...

  • 10:23:40

    DESJARDINSHmm. Wow.

  • 10:23:40

    PATEL...to really look at exactly what we're talking about. And, you know, remember this is a global issue, so we have researchers around the globe that have been affected areas -- Belize, other parts of South America -- who are also trying to understand the longer-term affects.

  • 10:23:54

    DESJARDINSOkay. Wonderful. Let's come back to this, to the United States. We're going to talk about the global impact in a few minutes. But I want to go to Florida now and to The Wall Street Journal reporter Arian Campo-Flores. Arian, can you tell us a little bit about what's happening there? We know Governor Rick Scott has now said he's going to set aside $5 million in state funding. How is that money going to be used and is that money enough? Or is that just the beginning of the next stage of response there?

  • 10:24:20

    MR. ARIAN CAMPO-FLORESI think it's probably the beginning of the next stage. I think local officials here are saying that the costs could escalate rapidly and they're asking for, you know, as much funding as they can get. That $5 million would go in large part to the mosquito control efforts that they've undertaken here -- the spraying that Dr. Fauci was describing, aerial spraying, backpack spraying. The state has also been offering free testing for pregnant women to see if they have been infected with the Zika virus. They're obviously investigating aggressively these new cases that are popping up to see if there are any additional local transmission zones that we need to be concerned about.

  • 10:25:06

    MR. ARIAN CAMPO-FLORESAt the county and city level, apart from the spraying, there are for instance in Miami Beach, some new vacuum trucks that the city purchased that they're using to clear out storm water systems.

  • 10:25:21

    DESJARDINSHmm.

  • 10:25:22

    CAMPO-FLORESThey have officials going through the city just to clear standing water. So a lot of this is obviously concentrated on trying to reduce that mosquito population and reduce the chances of infection.

  • 10:25:33

    DESJARDINSYou know, I keep trying to get my head around what life must be like there in Miami. On the one sense, really nothing has changed day to day in terms of stores that are open, people's jobs. But on the other hand, anyone who's interested in getting pregnant or who is pregnant or knows someone who is trying to get pregnant, has got to be thinking about this on a second-by-second timeframe. Can you give us a sense of what that's like. And do you know, I'm curious, is anyone who lives there leaving for a few months or thinking maybe they need to live somewhere else while this disease -- before we have this fully under control?

  • 10:26:10

    CAMPO-FLORESYeah. Absolutely. That's a great question. Yes, there's -- I mean, I think there's this sort of dividing line between if you're a pregnant woman or a couple seeking to become pregnant and the rest of the population.

  • 10:26:23

    DESJARDINSHmm.

  • 10:26:24

    CAMPO-FLORESObviously for those who are seeking to become pregnant or are pregnant, this is extremely worrisome. We did a story in the paper late last week that looked specifically at these groups of women who just feel like they've been basically imprisoned. They're worried about going out even to get the mail. Their lives have now just become entirely centered on what they can do inside. Play dates are being organized inside, no matter how little space you might have to work with and how rambunctious the kids might be.

  • 10:26:57

    CAMPO-FLORESAnd interestingly, in a response to that article, I received an email from a couple who told me that, because of this -- you know, the wife is pregnant -- they are leaving the state...

  • 10:27:11

    DESJARDINSWow.

  • 10:27:12

    CAMPO-FLORES...and are relocating to another state until the very last moment before which they can, you know, return and have the baby in Miami. So I think there's a high level of anxiety for that population.

  • 10:27:25

    DESJARDINSHmm.

  • 10:27:25

    CAMPO-FLORESFor the rest of the population, I think it varies. You know, there's some sort of, I think, low to mid level of concern with what's going on. My kids, for instance, just started to public schools yesterday and...

  • 10:27:41

    DESJARDINSHmm.

  • 10:27:41

    CAMPO-FLORES...you know, there's talk of how much repellant we should put on the kids. And, you know, whereas they would normally be having lunch outside, now they're going to be having lunch inside. So it's a concern. But so far, at least, it doesn't seem to have created, you know, a high level of anxiety among the tourists, who are so critical to this economy.

  • 10:28:00

    DESJARDINSThose who have still decided to go. Right. Yeah.

  • 10:28:04

    CAMPO-FLORESI'm sorry.

  • 10:28:04

    DESJARDINSThose who have still decided to go. Which I know some businesses are worried about the...

  • 10:28:07

    CAMPO-FLORESRight. Yeah. I mean, this was speaking to folks just in South Beach, you know, last week and over the weekend, it doesn't seem -- they don't seem overly concerned. Everybody's got their bug repellant and so far there has not been evidence of, you know, mass cancelations of reservations.

  • 10:28:23

    DESJARDINSOkay. Art Caplan, you are the director of medical ethics for New York University's Langone Medical Center. You know, we just heard a lot about fighting mosquitoes. We heard a lot about how people deal with this. What have we done right here? And what do we still need to do?

  • 10:28:39

    MR. ARTHUR CAPLANWell, we've done some things wrong. For one thing, this spread coming up from South American and Central America was easy to anticipate. We had an explosion of Zika in Puerto Rico. We didn't take effective measures there to kill off these mosquitoes. We haven't been warning people in Florida and I will say in the South generally about what they need to do to avoid mosquitoes and the other great unmentionable here, which we haven't said yet, sex. So there is a sexual transmission route, too.

  • 10:29:11

    MR. ARTHUR CAPLANIt's hard sometimes in the United States to talk about safe sex. We haven't done a great job in all populations with HIV. But here, again, you don't just want to put on the bug repellant. You probably want to be putting on a condom if you're in childbearing age. So we don't really have a good push in that direction. Amount of money Congress has allocated for Zika so far? Nothing. And that's been going on for months and no budget, so these outreach programs not there. We have not really had a serious discussion of genetically altering mosquitoes to tamp down the outbreak. It's probably much quicker that route than vaccines.

  • 10:29:53

    MR. ARTHUR CAPLANAnd I would say blood donation is another area where we need to alert people, you don't want this coming into the blood supply. We don't have a quick test. So in areas like Miami, it's probably the case that you have to be careful about thinking about being a blood donor. And obviously we need to compensate.

  • 10:30:10

    MR. ARTHUR CAPLANBut here's the biggest ethics issue. Should anybody be going to Miami or South Beach? So my view would be, if you're pregnant, no. If you're thinking about or trying to get pregnant, no. But that isn't the advice we've seen right now. It's kind of been, you know, maybe you don't want to travel there. The governor of Florida has been a little ambivalent.

  • 10:30:30

    DESJARDINSYou think it's been too mild, in other words. You think it's been too mild, to muddled.

  • 10:30:34

    CAPLANToo muddled, too mild, not really talking to the tourist bureaus, the convention sites.

  • 10:30:39

    DESJARDINSHmm.

  • 10:30:40

    CAPLANAnd not really, you know, taking on the issue about travel. Remember, in addition to getting bitten, you can also bring it back. We've had at least one case out of Florida that went all the way to Taiwan from a tourist.

  • 10:30:52

    DESJARDINSHmm.

  • 10:30:53

    CAPLANSo is the governor interested in setting up a fund to help compensate businesses that are damaged by loss of tourism?

  • 10:31:02

    DESJARDINSHmm.

  • 10:31:02

    CAPLANThat would get the message to be more vocal, because people aren't going to hurt their economic interests by talking about this in a serious way. So I love the CDC websites and I like this show. But I'm not sure we've had good communication to the people of Florida and the people of the United States yet about Zika.

  • 10:31:19

    DESJARDINSDo you think this is...

  • 10:31:20

    CAPLANOther than that, things are good.

  • 10:31:22

    DESJARDINSDo you think this is because, I know sometimes medical professionals, public health officials, they're more scared of the fear. You know, they don't want to incite unnecessary fear among a population. And obviously this disease...

  • 10:31:36

    CAPLANHmm.

  • 10:31:36

    DESJARDINS...is causing a lot of anxiety across the country. Do you think that's why the message has not been as sharp as you might have wanted it?

  • 10:31:44

    CAPLANWell, I'll say two things. One, I think we did have a lot of panic around Ebola. And that might have added more of a cautionary note to how we're going to respond to Zika. Remember we had quarantines and all kinds of sort of oddball public health measures. The other is sex. The government doesn't like to talk about sex.

  • 10:32:03

    DESJARDINSHmm. And I'm Lisa Desjardins. You're listening to "The Diane Rehm Show." Dina, we have a lot to talk about. Dina Fine Maron, you cover this from a science perspective. Let's talk about I think what Art first tackled, which is this idea of cases that we saw internationally, before we saw the first cases here. Can you talk about what's happening in the U.S. -- continental U.S. versus what's happening in the rest of the world and what that's teaching us or not teaching us?

  • 10:32:32

    MS. DINA FINE MARONSure. So a funny thing to really think about is I guess how we perceive risk here in the United States. As Dr. Fauci alluded to briefly, we've had more than 2,000 cases of Zika here in the United States. Almost all of them are travel related. But if you look just to Puerto Rico, a U.S. territory, there have been more than 8,000 cases of Zika virus, almost all of them locally transmitted, meaning mostly from mosquito bites, also from sexual transmission.

  • 10:32:58

    DESJARDINSThat's just a radically different scale.

  • 10:33:00

    MARONJust such a different scale.

  • 10:33:01

    DESJARDINSAnd it's much a smaller territory, yes.

  • 10:33:02

    MARONExactly. And so the U.S. public health response team is really learning a lot from how they're looking at tamping down the risk in Puerto Rico, and also at the real realities that many people are not in a financial position to pick up from their homes, from their jobs, from their families, to flee a real concern for some individuals, especially pregnant couples or those who are trying to become so. So it's really a more complex situation than we're giving it credit for.

  • 10:33:29

    DESJARDINSYou know, I'm trying to think the last time that we've had a disease in the continental United States that's sparked migration patterns, you know. In some degree, we saw this with flu pandemics in the past, I don't know how distant past. But do you know if we've seen anything like this in recent times where people have uprooted themselves from a disease hotspot?

  • 10:33:48

    MARONThat's a good question. Nothing really jumps to mind.

  • 10:33:50

    DESJARDINSYeah.

  • 10:33:51

    MARONOf course we had experiences in recent years with small pockets of Chikungunya and Dengue, both mosquito-borne diseases, both carried by the same species of mosquitoes we're talking about here. And those cases were in Texas and in Florida.

  • 10:34:04

    DESJARDINSHmm.

  • 10:34:05

    MARONAnd of course people were concerned about those situations and aftereffects of them. But they weren't thinking about birth defects, because that wasn't really part of the discussion.

  • 10:34:13

    DESJARDINSHmm.

  • 10:34:14

    MARONThat really is what incites the most concern and also what CDC is most concerned about. To Art Caplan's point, last week CDC did issue a warning about travel, especially for pregnant women. They said, pregnant women and their partners should postpone nonessential travel to all parts of Miami-Dade County. And they were really thinking primarily about pregnant people. Most of the response in the United States has focused on that population.

  • 10:34:39

    DESJARDINSOkay. Quickly, we're going to take a phone call from Jim in Washington, D.C. The theme this hour has not just been Zika but the mosquito. And, Jim, you say you've got some advice. You used to work at the EPA. Tell us what your advice is.

  • 10:34:52

    JIMRight. Well, just a caution. That given some quirk in the regulation that the EPA has to regulate insect repellants -- and they're a pesticide, so EPA has jurisdiction over that -- they -- there is a big difference between whether or not a label says, repels mosquitoes, versus, repels mosquitoes that may cause a disease, like West Nile virus or Zika or something like that. And the key distinction is, if it doesn't have that public health -- what EPA calls the public health claim -- if it doesn't talk about a disease and the mosquitoes or whatever insect may cause a disease, it's a product which has basically been deregulated under EPA's regulations.

  • 10:35:31

    DESJARDINSHmm.

  • 10:35:32

    JIMAnd that means it's not reviewed by EPA.

  • 10:35:36

    DESJARDINSSo when someone looks at the label, one more time, Jim, what should they focus in on?

  • 10:35:41

    JIMThey need to see the words repels -- not only repels mosquitoes, but also something about a disease. Like when...

  • 10:35:47

    DESJARDINSOkay.

  • 10:35:48

    JIMUsually, the products on the market today -- because Zika's a bit of a more recent thing -- it'll say West Nile virus and things like that.

  • 10:35:55

    DESJARDINSOkay.

  • 10:35:55

    JIMIf it makes that claim about disease, EPA has to review it.

  • 10:35:58

    DESJARDINSJim, thank you so much for that call. Dina.

  • 10:36:01

    MARONJust to add to that -- and maybe Dr. Patel wants to speak to this as well -- but CDC and the Association for Gynecologists and Obstetricians has said you should follow the instructions, look for a product that has DEET or another approved substance. Any of those are fine, even if you're pregnant.

  • 10:36:16

    PATELRight. That's...

  • 10:36:16

    DESJARDINSDr. Kavita Patel, yes.

  • 10:36:17

    PATELYeah, that's correct. I was just going to say, sometimes it can be confusing if you don't see the right language. So DEET would be the one to concentrate on.

  • 10:36:24

    DESJARDINSOkay. And, Dina Fine Maron, we have a question from email from E.J. When did the Zika virus really become active? How long has it been around?

  • 10:36:33

    MARONYeah. So it's a good question because we think Zika virus has just popped into public consciousness. But actually we discovered it back in 1947...

  • 10:36:40

    DESJARDINSWow.

  • 10:36:40

    MARON...in Uganda. But what's interesting is between that discovery in Uganda in monkeys there about 50 years before it even showed up in our radar. That was because it primarily just occurred in remote locations. It didn't seem to cause that much illness. There are only about a dozen cases in the peer-review literature before 2007. And that is because -- in part because Zika virus seems so mild. It seems like only -- four out of five people have no symptoms at all. Those who do would get a fever, a mild rash. Then in 2007, there was the first large outbreak in humans. And that's when we started really thinking about it.

  • 10:37:15

    MARONBut it wasn't until the last few years, of course, that it really exploded in Latin America. But even then, we didn't realize at first that it was as big a threat as it is.

  • 10:37:24

    DESJARDINSOkay. Dina Fine Maron with Scientific American. We're going to continue taking your calls. Obviously, this is an important topic and a fascinating one. So stay tuned. We'll be right back after this break.

  • 10:39:58

    DESJARDINSAnd welcome back. I'm Lisa Desjardins sitting in for Diane Rehm. 2016 has produced many unexpected stories. Among them, of course, is the Zika virus. And we're talking about that this hour. We have an email right now from Donya, asking, if you are infected with Zika during the second or third trimester, is your baby less likely to have a problem? We tackled this a little bit at the beginning, but can you take us through, first of all, when can you -- when in a pregnancy can you diagnose? You mentioned this before, but I want to really stress, when can you diagnose if a fetus is -- has been exposed to Zika and is experiencing problems and then when in pregnancy is there a safe time. Is there a safe time?

  • 10:40:39

    PATELRight, so the literature is truly actually emerging in a real-time basis. Here's what we know. We know that a pregnant woman, the mother can be tested at any point in the pregnancy and have the Zika virus, but then we know that especially the birth defects that everybody is concerned about, rightfully so with that microcephaly, the small brain development, or even potentially the worst-case scenario for many mothers is whether the baby would be still born, that we know that the earliest signs that you can see ultrasound evidence of that is between 16 to 20 weeks.

  • 10:41:18

    PATELSo again, we can test at any point in the pregnancy for whether the mother has the virus, remember we do that through that blood test that Dr. Fauci mentioned, but then we have to check both ultrasounds, as well as checking amniotic fluid and placentic blood sampling to see if there's evidence of the disease.

  • 10:41:37

    PATELHowever, the questioner is asking if they're in the second or third trimester is it worse, or is it better, and we do now know if a certain time period for the pregnant mother is worse or better, if that makes sense, Lisa.

  • 10:41:50

    DESJARDINSOkay.

  • 10:41:51

    PATELSo the safest recommendations is to make sure that anybody who has had any sort of exposure and is either childbearing, thinking about becoming pregnant or is pregnant, get tested immediately, and then the OB will start to monitor that brain development.

  • 10:42:08

    DESJARDINSThis raises a -- what can be a devastating discussion for families and for women about if you have a pregnancy where you think the child has been exposed to Zika, and you're concerned about the child's development, what do you do. And I want to go to Arian Campo-Flores. Marco Rubio spoke out against abortion as an option for pregnant women in a recent interview with Politico, and we know that this has been part of the conversation around abortion before. Arian, tell me what that debate is like in Florida right now.

  • 10:42:38

    CAMPO-FLORESYeah, well, the -- I spoke to a doctor for a piece we did recently on this who is overseeing the care of roughly a dozen pregnant women who have -- are infected with Zika. And it's obviously a very wrenching and difficult decision that they face. Some take the attitude of, you know, whatever the world or whatever, you know, God may bring me, I'm going to go with it and see this pregnancy through. For other it is -- becomes this kind of difficult exercise in risk assessment and deciding whether these are risks that they can live with or not.

  • 10:43:23

    CAMPO-FLORESAnd some may choose to terminate a pregnancy as a result. The complicating factor here is what Dr. Patel was just describing, which is that oftentimes you don't -- you may not find out about the potential for there to be a birth defect until later in the pregnancy, and the later you get in a pregnancy, the less abortion becomes an option, particularly in states like Florida and elsewhere in the South, where there are restrictions on late-term abortions.

  • 10:43:56

    DESJARDINSAnd we know now in state legislatures in the past, for the past couple of years, there's really been a debate as conservatives has said we think that the abortion bright line is too late now. They'd like to move it back to 20 weeks. It's approximately at 24 weeks right now, considered viability. Art Caplan with Langone Medical Center Division of Ethics, who is it that should be weighing in on this kind of very difficult debate?

  • 10:44:23

    CAPLANWell, I think we need to hear from our legislators. Abortion not only is restricted in late pregnancy, but in Texas, Mississippi, Louisiana, places where this disease is likely to go, it's restricted in terms of access for all women. So we have a real problem here in terms of reproductive health. If you look at polls, people support the legitimacy of abortion, the number one rationale being rape and incest but number two is severe defect of the fetus.

  • 10:44:55

    CAPLANSo the vast majority of Americans believe that to be a moral reason to end a pregnancy. Not everyone will choose to do so. It does seem to me availability here is crucial, and by the way, the fight over this issue is what held up congressional funding for Zika. So they couldn't get an agreement on the ornaments that they hung on the bill about restricting abortion, and so they wound up doing nothing.

  • 10:45:21

    CAPLANI think that's wrong. I think people should have a right to decide how they want to manage these pregnancies in terms of dealing with a severe, usually life-shortening defect, and, you know, we're basically making that decision for the women when we say that there's only one clinic in Louisiana or only one clinic that you can get to in vast swaths of Texas.

  • 10:45:49

    DESJARDINSDina Fine Maron with Scientific American, can you take us through that debate? I cover Congress, and so I'm very familiar with what's happening right now, which is Democrats are saying Republicans are holding up the money because Republicans do not want Planned Parenthood to have access to Zika funding. Republicans are saying no, it's Democrats that are holding it up because we think that, you know, keeping Planned Parenthood out of it is reasonable. They're both making arguments about Planned Parenthood, and as a result this funding is being held up. Can you take us through this debate? How do you -- what do you know about this?

  • 10:46:20

    MARONYeah, so what we're talking about here is $1.9 billion, that's billion with a B, and that money would go not just towards mosquito control but also towards education, which is something Art Caplan is talking about he was concerned with, also some international aid, some research, and that was requested back in February. And of course lawmakers did go on their summer recess without moving forward with any further discussion, and the talk now is...

  • 10:46:44

    DESJARDINSSeven-week recess.

  • 10:46:45

    MARONExactly, and the talk now as we're approaching November elections, of course, is is this going to be an important election issue as Zika is more in people's consciousness, especially after the recent flooding in Louisiana and concerns about standing water around those 60,000 homes that were really hurt by this recent disaster. Is this going to be something that people are going to say, to their lawmakers, how come you didn't do anything about this? I'm concerned about this, I have family members who are concerned about this. Why aren't we getting something done?

  • 10:47:18

    MARONAs a stop-gap measure, of course, federal government, NIH specifically, has shifted funding that they were gearing towards different response issues, Ebola primarily, towards trying to tamp down Zika. But that's only a stop-gap measure, especially according to the vaccine discussion. Phase 2 trials for the vaccines, as Dr. Fauci alluded to, would require thousands of people in them and would take place in Latin America and in the Caribbean, and that of course requires a lot of money to get off the ground, and Dr. Fauci has expressed concern that that Phase 2 trial effort couldn't really happen without further funding.

  • 10:47:55

    DESJARDINSAnd they need to be able to plan that, too.

  • 10:47:56

    MARONExactly.

  • 10:47:58

    DESJARDINSThey need to be able to get that moving and get the kind of...

  • 10:47:59

    MARONYou need people on the ground, those relationships starting to build and also literally transport of thousands of vials of potential vaccine to a new location is also a stiff order.

  • 10:48:09

    DESJARDINSDina Fine Maron with Scientific American. Let's go back to the phones and Mindy in Michigan. Mindy, you're on the air.

  • 10:48:16

    MINDYHi, I have a quick question. My son did a study abroad program in Cuba this summer. He's been home for a few weeks. He's back at school now. What I'm concerned about, he didn't get tested, he had no symptoms at all, but was he communicable if he got it and didn't show symptoms? Now he's back on a college campus. He had contact with his girlfriend, who's on another college campus. How -- how concerning is it for the kids or people who may have been exposed but didn't show symptoms, who may have it but aren't getting tested?

  • 10:48:56

    DESJARDINSMindy, that is a great question. I think almost every one of our panelists are jumping to answer it. I think we can go to you, Dr. Patel.

  • 10:49:02

    PATELSure, and I think Dina also has some statistics to help with this.

  • 10:49:06

    DESJARDINSYeah.

  • 10:49:07

    PATELAgain, I think you have to look at whether or not the countries themselves have a high, like, probability. In this case I think Dina's going to talk about Cuba, but in the case, in the scenario that's just been described, we would go through a risk assessment with your son, and honestly that would be a low likelihood for any sort of disease transmission. And so that would -- I think that any caller who has a family member or themselves are concerned, doing exactly what the caller did and kind of going through the history, which includes travel history, and then also, as she mentioned, I think partners, girlfriends, sexual contacts are critical. But in this case it's a very low likelihood, and I think Dina was going to talk a little bit about Cuba and for example.

  • 10:49:53

    DESJARDINSI mean, I'll take it to Dina and Cuba in just a second, but one thing as I was getting ready for this show that I felt was not out there enough is the idea that if you are infected with Zika, your body actually can eradicate -- eradicates it itself over time. Is that right?

  • 10:50:05

    PATELCorrect.

  • 10:50:07

    DESJARDINSHow long does that take? You basically can fully recover from Zika and get to a place where you...

  • 10:50:11

    PATELAre free of the virus after several weeks, actually, so...

  • 10:50:16

    DESJARDINSOkay, two to three weeks? Right.

  • 10:50:16

    PATELSo we actually give precautions for -- we think that men clear it from their semen longer. So we usually give a precaution around six to eight weeks in which they should have at least, at the absolute minimum like Dr. Caplan said, a condom in usage when sexual...

  • 10:50:31

    DESJARDINSAnd I've seen six months just to err on the side of caution there for men.

  • 10:50:33

    PATELExactly. So we've seen -- you know, we seen lab definitive clearing in semen and blood, remember this is how it's transmitted from human to human, so this -- you know, sexual practices, are well as blood transmission. So we can see clearing in weeks, but we do advise for people who are especially in childbearing years to have potentially months of precaution. And I think again this is one of those areas where across the country people are calling with questions because of travel.

  • 10:51:02

    DESJARDINSRight.

  • 10:51:04

    PATELI have been very clear with patients to not mince words. Do not travel to these areas. And I've had many patients who are actually either thinking about becoming pregnant or pregnant who have said, but I've bought my tickets, and I have said we will write you letters, and we will do what we can, do not take the risks to these high endemic areas.

  • 10:51:22

    DESJARDINSDo Mindy, I think the answer to your question is it sounds like your son is relative low risk, but depending on when he was exposed, the disease may have already cleared on its own. Does that help?

  • 10:51:33

    PATELAnd pregnant -- and pregnant women also clear the disease, and we think that they have no risk for future pregnancies.

  • 10:51:39

    DESJARDINSOkay.

  • 10:51:39

    PATELSo even women, this is a tragic for any woman who's having to deal with this with an active pregnancy, but the concern is whether or not they can have future pregnancies, and we think that yes, they can have safe future pregnancies.

  • 10:51:52

    DESJARDINSOkay, and I'm Lisa Desjardins, you're listening to the Diane Rehm Show. Dina, you were going to talk about Cuba and what we know. This is -- we had this woman whose son just traveled to Cuba.

  • 10:52:03

    MARONSure, so just briefly, historically Cuba has been very praiseworthy in terms of mosquito eradication. Originally the World Health Organization thought Cuba would be one of the few countries that wasn't going to see any local Zika cases at all. They have seen, at least count that I checked, three, three local cases, which obviously is extremely small, and in response to those cases they have been all about spraying from the air, as well as from the ground to try to reduce any future risk.

  • 10:52:32

    DESJARDINSCan you break down the vaccines for us? I know this is everyone's hope, and Dr. Fauci, for those who are tuning in later in the show, Dr. Fauci from NIH told us earlier in the show that he doesn't think vaccines will be available until 2018, and that's actually...

  • 10:52:45

    PATELAt the earliest.

  • 10:52:45

    DESJARDINSRight, and that's actually speedy for a vaccine. But can you break down where we are, what we know about these vaccines?

  • 10:52:50

    PATELSure, so there are a handful of candidates we're talking about. The two that are furthest through the pipeline are those Phase 1 vaccines. One is sponsored by the National Institutes of Health, and one is sponsored by a private pharmaceutical company called Inovio that is based out of Pennsylvania. But both of them are very similar in that they are called DNA vaccines. That means instead of vaccines we typically think of that have an inactivated live or dead virus, for example, and those of course are designed to spark an immune response in the body that would lead to antibodies to fight off a virus, these just contain a particular part of the pathogen.

  • 10:53:24

    DESJARDINSOkay.

  • 10:53:24

    PATELSo they contain -- what that means is, to get into further detail, they contain just a circular plasmid of DNA with the genes of the specific proteins of the Zika virus inserted into it. And so that's going to act the same way as another vaccine, namely getting your body to be able to fight it off.

  • 10:53:38

    DESJARDINSAnd that's an advance, right? That's a huge advance.

  • 10:53:39

    PATELIt's a huge advance. There have never been any other vaccines for humans that were designed like this. There have been some for veterinary purposes but not for humans.

  • 10:53:46

    DESJARDINSAnd is that the nature of this disease, or is that sort of the urgency of dealing with it that's generating this innovation?

  • 10:53:53

    PATELThat's a good question. It's -- it has been -- this kind of vaccine has been discussed for other contexts, but it never moved forward. There was some research with West Nile Virus that we were able to piggyback off for this, but we haven't actually had one in the past.

  • 10:54:07

    DESJARDINSWe're going to come back and go to Art Caplan, but we just got an interesting call from Puerto Rico. We've got a public health official on the line. Manuel, tell us what it is like there to be a public health official in Puerto Rico fighting Zika.

  • 10:54:20

    MANUELNo, correction, I am not a public health official. I deal with public health entomology.

  • 10:54:25

    DESJARDINSOh, I see. Thank you for correcting me. Well, tell me what it is like being on the ground there.

  • 10:54:29

    MANUELThe problem we have here in Puerto Rico is that microcephaly, everybody focuses on microcephaly, and microcephaly is the manifestation or the extreme manifestation of the problem. And I have contacts here in the obstetrics and gynecology sections, and they have been detecting malformations in some kids that are not being born yet. And, you know, the problem -- Margaret Chan, director of the World Health Organization, summarized the problem with Zika at the recent World Health Assembly, and what she said was simple, that the problem we have with Zika is a manifestation of a failure to do mosquito control.

  • 10:55:10

    MANUELAedes aegypti was eradicated from the South American continent back in '60-something, '67 or '68, and here we are. And after the eradication of the aegypti, dealing with Dengue at the time, after eradication of aegypti from South America, essentially the programs, the mosquito-control programs, were told thank you very much, we don't need you anymore. And here we are.

  • 10:55:34

    DESJARDINSManuel, thank you for that call. Art Caplan, I want to go to you on that note. I know you have a lot of thoughts, but that is a public health and ethics issue that we're hearing right, from Puerto Rico, and you could hear in Manuel's voice his frustration and a heaviness on him because of this disease.

  • 10:55:50

    CAPLANAbsolutely. So we haven't built our infrastructure for public health to deal with any mosquito-borne diseases in the U.S., there are others besides Zika, and I think those should be budgeted. I mentioned earlier there is genetic engineering to make sterile mosquitoes. It seems to me safer, cheaper and actually more effective. Spraying isn't that great with this kind of Zika mosquito. So Florida is going to take a vote on that in November, and it is a way to make sterile mosquitoes of that subspecies and get rid of them without spraying the whole world with pesticide or ourselves.

  • 10:56:26

    DESJARDINSHas that been done on -- has that been done on a wide scale?

  • 10:56:28

    CAPLANIt's just been done experimentally in a couple of small places. Cayman Islands did it with good success, by the way. One other -- well, two other quick points. One is I think it was clearly said, and I want to reinforce it, if you have been in a Zika area, you should not be engaged in unsafe sex. So for men, you know, three months or you should wear a condom, and we've got to be blunt about that. That's the advice I would give to someone who's been in a place where Zika has been, be prudent, and don't try to have a child for a little while, until you're pretty likely to have cleared the virus.

  • 10:57:03

    CAPLANOther comment, don't go to Zika areas. And we could do something about that, making that possible, if we would treat this more like a flood or a hurricane and set up some relief programs for people affected by the impact on tourism.

  • 10:57:16

    DESJARDINSOkay, Arthur Caplan from New York University's Langone Medical Center. Thank you so much for joining us. And I have to thank the rest of our panel. What an incredibly important and informative show. I personally want to thank you, Dr. Kavita Patel, you're a fellow with the Brookings Institution. You're also a primary care physician getting a lot of emails and photos this day -- these days from concerned people. Dina Fine Maron from the Scientific American and also in Florida we have Arian Campo-Flores from The Wall Street Journal. Thank you all so much for joining us. I'm Lisa Desjardins. We wish you all well.

Related Links

Topics + Tags

Comments

comments powered by Disqus
Most Recent Shows