On Thursday, February 11, Venezuelan President Nicolás Maduro announced that at least three people had died due to complications related to the mosquito-borne Zika virus. These are the first Zika-related deaths in the South American country. Maduro also confirmed that 68 other people were in “intensive care” due to complications related to the virus. Since November 2015, Venezuela has recorded more than 5,000 suspected cases. The virus is spreading rapidly through South and Central America and is likely to result in some four million new cases this year.

At this stage, at least 20 countries have registered local transmission of the disease. Borne by theAedes mosquito, the disease produces no symptoms in the majority of cases and only mild symptoms such as fever, rash, severe headache and joint pain in other individuals. Despite this, the alarm surrounding Zika’s rapid spread through the Americas has reached fever-pitch in recent weeks as researchers draw correlations between infected mothers and infants born with microcephaly. Several studies are currently underway to conclusively determine the connection between the virus and microcephaly, but so far have been unsuccessful, showing only a strong causality.

In recent days suspicions have been raised by a group of Argentine physicians as to whether or not Brazil’s microcephaly crisis actually has Zika to blame. The World Health Organization (WHO) has been careful not to explicitly link Zika to microcephaly. WHO General Director Margaret Chan stated, “Although a causal link between Zika infection in pregnancy and microcephaly — and I must emphasize — has not been established, the circumstantial evidence is suggestive and extremely worrisome.”

The group of Argentine doctors suspects that, instead, a toxic chemical introduced into Brazil’s water supplies in 2014 to prevent the development of mosquito larvae in drinking water may be the real culprit. The larvicide, known as Pyriproxyfen, was used in a massive government-run program to control the mosquito population in the country. The group has pointed out that in previous Zika epidemics, microcephaly has never been linked to the disease. Further supporting their claim, the Columbian president has announced that, despite there being a widespread Zika outbreak in Colombia, there is not a single case of microcephaly there.

Meanwhile, the virus continues to spread. Russian authorities reported on Monday, February 15, that health officials have detected the country’s first case of the Zika virus in a patient who had recently visited the Dominican Republic. Russian citizens are medically tested upon return from countries affected by the Zika virus. Last week, Queensland’s Department of Health confirmed Australia’s third imported case of the Zika virus within a week, following two patients who contracted the virus in Samoa and El Salvador, respectively. It is also the first confirmed case of the virus in a pregnant woman in Australia. Health authorities in Australia have assured people that the reported cases do not pose a risk to those who have not recently traveled to a Zika-affected territory and that they would continue to enforce stringent monitoring at the country’s ports of entry.

In more encouraging news, the WHO has released a global Strategic Response Framework and Joint Operations Plan to help guide the international response to the frightening spread of Zika and the associated neonatal malformations and neurological conditions. The strategy will focus on “mobilizing and coordinating partners, experts and resources to help countries enhance surveillance of the Zika virus and disorders that could be linked to it, improve vector control, effectively communicate risks, guidance and protection measures, provide medical care to those affected and fast-track research and development of vaccines, diagnostics and therapeutics.”

Early in her pregnancy, Whitney Peak traveled to Rio de Janeiro for her job with Leblon Cachaça, a liquor company based in Brazil. That was in October, before much was known about Zika, a mosquito-borne virus that has spread through South America and that scientists say may be linked to a birth defect and brain damage in babies.

She was scheduled to return to Rio in late January for some Olympics-related marketing projects. But after consulting with colleagues, she canceled the second visit — and now regrets the first.

“It is very scary to know I could have unknowingly put my child at risk,” said Ms. Peak, who is still pregnant. “When the time came for the planned trip, I don’t think there was any question that the risk for me to go was too high.”

With reports of Zika infections on the rise, employees and management at a variety of corporations are grappling with how to handle jobs and projects in affected regions.

The virus has created widespread anxiety in countries in the Caribbean and Latin and South America, home to thousands of foreign workers. As the scientific community tries to learn more about Zika — which appears to be linked to microcephaly, which causes babies to be born with unusually small heads — companies are trying to establish policies that juggle both personal privacy and potential health hazards.

With much about Zika unknown, many companies are taking a safety-first approach.

Since mid-January, Delta Air Lines has offered the option for any pilot or flight attendant to swap out a scheduled trip if traveling to areas flagged by the Centers for Disease Control and Prevention. In an email, a spokesman for the airline said that to date, a small number of crew members have swapped trips.

Kimberly-Clark, the maker of paper products based in Irving, Tex., is educating its 16,000 employees in affected regions with information about how to protect against the virus — from what type of clothing to wear to the benefits of insect repellent.

“We quickly issued travel advisories, trying to ensure that any travel to the region is for critical business and not a normal run-of-the-mill kind of business meeting,” said Bob Brand, a spokesman for Kimberly-Clark. “We’ve always had pretty extensive pest control measures in place because we operate in countries that have always seen a number of mosquito-borne diseases, but we are stepping up our pest-control measures to make our operations as safe as possible.”

The United States Department of Defense is offering to relocate any pregnant family members of active-duty or civilian military personnel assigned to areas affected by the Zika virus transmission. And on Feb. 4, The New York Times sent an email to employees about Zika, saying that they did not have to accept any assignment that made them feel “uncomfortable about their own well-being” and that they did not need to tell their managers why they were opting out of any assignments.

Corporate medical officers are conferring with people like David O. Freedman, a professor of medicine and epidemiology and founder of the Travelers Health Clinic at the University of Alabama at Birmingham. He said that because worries about the Zika virus are enmeshed with family planning issues, setting guidelines about it is tricky.

“There are all sorts of legal implications and legal restrictions,” he said. “Do you even hint at advising your female employees not to get pregnant for the next two years, while posted in Brazil?”

And what if a company evacuates its female employees, or urges them to leave a country, he asked. What message does it send if that company also has employees who are native to the country, people who presumably don’t have the same option? The possibility that the virus can be transmitted sexually presents another drawback and may give pause to men who want to have children.

Few companies will speak openly about their Zika policy. A number of multinationals with significant operations in Latin or South America either did not return calls or offered carefully worded statements about “closely monitoring” the situation.

The region is popular with cruise lines and conferences, but Carnival Corporation said it has had only a “few cancellations” on its cruise ships, noting that pregnant women who wish to cancel will be provided alternate itinerary options or can reschedule their voyage for a later date. Four Boston public schools canceled field trips to the Dominican Republic,Ecuador and Nicaragua. A conference in Puerto Rico planned for September — the country’s convention bureau could not recall which one — is being moved to the next spring.

In the region, concern has not yielded to panic. The level of alarm in cities like Rio, in fact, seems lower than in the United States. The national and local news media in Brazil are reporting findings by organizations like the World Health Organization, which called Zika a global health emergency. But Brazilians have dealt with mosquito-borne viruses for a long time, and some of the viruses, like dengue fever, are more feared because they have affected far more people.

Notes of skepticism, or at least pleas for reactions commensurate with the threat, have become part of the newspaper coverage. On Feb. 4, El País, a Spanish newspaper with a Brazilian edition, published a story online with the headline “Is the risk of Zika exaggerated?” The subhead stated, in part, “Lack of scientific knowledge of the virus and its effects on babies inflates number of possible cases.”

One person who is not changing her itinerary is Anna Holzer, a 32-year-old doctor from Polk City, Iowa. In early February, she traveled to the Dominican Republic for medical seminars by the Iowa Academy of Family Physicians. To be sure she knew the risks, she called up Iowa’s state epidemiologist to discuss precautions.

“We just don’t know much about the virus, how it works, the microcephaly connection,” said Dr. Holzer, who noted that some of her patients had asked whether they should travel to affected regions.

“Women who are pregnant shouldn’t be going. And women who are planning to become pregnant should probably wait a month before attempting to conceive,” Dr. Holzer said in a telephone interview before taking her trip. “But other than taking the precaution of using more repellent, I’m planning on enjoying my vacation.”

Just over a year ago, we faced a similar challenge when Ebola was spiraling out of control. At the time, two of us (Ranu and Devabhaktuni) were asked by the president of Guinea, one of the three most affected countries, to help develop a national strategy to contain the epidemic. Based on our experience fighting Ebola, we propose a four-pronged strategy for containing Zika.

Just like Ebola, there is no vaccine or cure for Zika and will likely not be one for years. Stopping this pandemic will require disrupting its “chains of transmission.” For Ebola, which is transmitted through bodily fluids (e.g., blood, stool), this meant implementing a response that identified newly infected people at the first sign of illness and then quarantined them before they infected others.

Controlling Zika, which is transmitted by mosquitoes and apparently through sex, might logically require eliminating mosquitoes in areas where the virus is present and immediately isolating infected people, especially from pregnant women. This can be done by ensuring people use mosquito repellents and sleep under insecticide-treated bed nets (similar to those that have helped achieve dramatic declines in malaria in Africa) and by eliminating conditions where mosquitoes thrive, including standing water and outdoor debris. However, because 80% of infected people show no signs of illness and others have nonspecific symptoms like fever and body aches, it is hard to know who has Zika and, therefore, pinpoint areas where these interventions need to be targeted.

Right now, affected countries are identifying local hot spots by looking for places where there are unusually high rates of babies born with microcephaly — essentially, only after severe damage has already been done. Some countries are currently trying to contain Zika by broadly recommending that all women avoid becoming pregnant and that communities take precautions against mosquitoes. But implementing these measures across entire countries will require massive changes in attitude and behavior and the mass distribution of both birth-control and mosquito-control commodities. (For example, by some estimates over half of pregnancies in the region are unintended.) These approaches will only be partially effective at large scale; pregnancies will certainly still occur and some mosquitoes will still remain.

Therefore, alongside such broad-brush efforts, a more nuanced and intensive four-pronged response is needed.

1. Pinpoint Hot Spots With Widespread Testing

In areas where Zika may be present, all patients with symptoms that could signify infection should be screened by blood testing so that hot spots can be quickly detected. This approach would benefit from the accelerated development of easy-to-use, point-of-care diagnostics for Zika.

Similar to Ebola, Zika diagnosis currently requires polymerase chain reaction (PCR), a laboratory-based test that needs special equipment and personnel and is, therefore, difficult to scale and decentralize. One of the major failures during the Ebola epidemic was the inability to quickly validate and deploy rapid diagnostic tests (RDTs) that could have been used by non-specialized health workers to diagnose Ebola within minutes with just a finger prick. This would have allowed Ebola cases to be detected earlier and transmission to be curbed more quickly. These diagnostics could have helped end the epidemic much sooner, but were never deployed because of a lack of consensus on how they should be used as well as a validation process focused on laboratory-based evaluations rather than testing in real-life conditions where the RDT ultimately performed much better.

Developing a similar test for Zika should be an immediate priority and proactively coordinated and pushed forward with dedicated financing and a fast-track validation process geared towards evaluating new tests in the field as soon as possible. In the meantime, existing labs at regional and sub-regional hospitals should be urgently equipped to carry out Zika diagnosis by PCR so surveillance of the virus’ spread can begin immediately.

2. Implement Targeted Control Measures

With information on where Zika transmission is happening, mosquito control and isolation interventions can be aggressively implemented in these areas. Bed nets and repellant should be distributed to all households, environmental conditions conducive to mosquito breeding should be addressed, and people diagnosed with Zika should be kept away from pregnant women and settings where mosquitoes can feed on them.  Implementing this intensive response requires effective local health systems. In the Ebola epidemic, the affected countries in West Africa had barely functioning health systems, especially at the local level. As a result, we had to create a parallel Ebola-specific response system at great cost and time, all while the epidemic continued to expand.

Many of the countries currently affected by Zika have relatively stronger health systems. In Brazil, the most heavily affected country, for example, there is already a network of local clinics linked to community health workers who go from household to household to address health issues. These local health systems should pivot towards epidemic control and search out potential cases of Zika while providing counseling and close monitoring to pregnant women in order to minimize their risk of infection. Extra personnel, training, and resources should be deployed to fortify these existing systems to implement the interventions needed to tame Zika.

3. Prevent Widespread Transmission

At the start of the West African Ebola epidemic, the virus was clustered within a few local communities and, as in the two-dozen Ebola outbreaks before it, could have been confined and brought to a quick end. However, once Ebola eluded early response efforts and became a widespread epidemic of multiple, dispersed local outbreaks, it became a true global crisis difficult to bring back under control.

Zika has already become fairly widespread. But every effort should be made to try to pin the virus down in its current locations and stop it from reaching new geographies. Once a hot spot is identified, people traveling out of the area should be tested at diagnostic checkpoints. The point-of-care diagnostic we described above would dramatically enhance the ability to implement this approach.

4. Integrate Research with Immediate Action

With Ebola, we tried to manage the epidemic even while many critical questions about the virus remained unanswered. Despite thousands of cases and over two years of fighting the epidemic, we still did not learn as much as we should have about Ebola because of an inability to conduct effective research alongside efforts to manage the epidemic.

With Zika, we may have even more knowledge blind spots that need to be quickly understood if the pandemic is going to be contained. Does Zika actually cause microcephaly and paralysis as is suspected? If so, is everyone vulnerable or only people with certain characteristics? We should learn from mistakes we made with Ebola and deliberately consider how important research questions can be studied even while we work to immediately control the virus. Doing this will undoubtedly require bolstering the research capacity of local universities and institutions, a critical investment that we did not make during Ebola.

This four-pronged strategy should enable us to get ahead of this growing pandemic and prevent what now seems to be the inevitable spread of Zika across the globe. Amidst the chaos of the Ebola epidemic, a clear-sighted approach to disrupting the “chain of transmission” tamed runaway growth. We must heed the lessons from the Ebola crisis and employ a systematic, concrete strategy to combat the spread of  Zika.

______________________________________________________

Authors:

Ranu S. Dhillon, MD, is an advisor to the president of Guinea and the country’s National Ebola Coordination Cell. He is in the division of global health equity at Brigham and Women’s Hospital and Harvard Medical School and is a senior health advisor at Columbia University’s Earth Institute.

Robert Glatter, MD, is an assistant professor of emergency medicine in the Department of Emergency Medicine at Northwell Health’s Lenox Hill Hospital. He is editor at large at Medscape Emergency Medicine and chief editor at Medscape Consult.

Devabhaktuni Srikrishna is the founder of Patient Knowhow, which curates patient educational content on YouTube. Previously, he was founder and chief technology officer of Tropos Networks, which was acquired by ABB Group.

Since Zika was detected in Brazil last year, the mosquito-borne virus has spread to 33 countries, most of them in the Americas.

The World Health Organization declared an international health emergency because of strong suspicions that infections in pregnant women may cause microcephaly, a condition in which infants are born with abnormally small heads and can suffer developmental problems.

While the virus had typically caused mild symptoms in adults, it also has been linked to an autoimmune disorder called Guillain-Barre syndrome that can cause paralysis.

U.S. and world health authorities are not currently warning against all travel to affected areas, as they did with the 2014 Ebola outbreak in West Africa. They are, however, advising pregnant women to consider postponing travel, and all travelers to take precautions to avoid mosquito bites. Adherence to the recommendations of the U.S. Department of State or the World Health Organization would shield companies to a large degree from claims they acted recklessly in sending employees into Zika-affected areas, lawyers who typically represent employers say.

The U.S. Centers for Disease Control and Prevention (CDC) further recommends that travelers wear insect repellent and sleep with mosquito nets in places where they might be bitten, among other measures.

“Your defense to any sort of claim is that you follow the public health guidance,” said Mark Lies, a lawyer with the firm Seyfarth Shaw, which specializes in advising companies on employment issues.

Such advisories also mean workers probably would not be protected from termination if they refuse to go to an affected area, lawyers said. While the federal Occupational Safety and Health Act gives workers the right to refuse dangerous tasks, those tasks must pose an immediate risk of death or serious injury.

Something like working with a “defective tool that has electrical sparks coming out of it” would meet that standard, said Ben Huggett of Littler, another employment law firm. Traveling to a Zika-affected area, on the other hand, would probably not, he said.

Lies said upgraded warnings in the event Zika proves more lethal or virulent could give workers more of a right to refuse travel. But he said OSHA affords no special protection for pregnant women under current threat levels. The law governs only the safety of employees, not any unborn children they may be carrying.

If employees contract Zika while traveling on the job, any immediate harm they suffer would be covered by worker’s compensation insurance, a form of no-fault insurance that applies to injuries suffered on the job. Virtually all states require employers to obtain worker’s compensation insurance and mandate that it be the sole remedy for workplace injuries.

Worker’s compensation covers lost wages and medical care but awards are typically smaller than private lawsuits, which can seek to recover damages for pain and suffering, as well as punitive damages for negligence.

Whether worker’s compensation would cover any purported Zika-related injuries in an employee’s baby is less clear. Huggett said that a fetal injury might be covered as being derivative of the mother’s injury.

Huggett said he was unaware of any case that directly addressed worker’s compensation for a fetus harmed by an infectious disease. “It’s really an open question,” he said.

Lies said he did not believe worker’s compensation would generally cover injury to a fetus but thought it could open the door for an employee to bring a lawsuit against her employer for negligence.

“If someone is pregnant, or trying to get pregnant, or could get pregnant, you could have a case,” said Katherine Dudley Helms, a lawyer with employment law firm Ogletree Deakins.

Many states limit worker’s compensation to several years’ pay, while a damage award for a severely impaired child could reach tens of millions of dollars, according to Michael Jones, an employment lawyer with Reed Smith.

Michael Gerson of California firm Boxer & Gerson, who brings claims on behalf of employees, said such a case would still be a challenge if the company followed official warnings. The evidence would have to show “that the mother was never given adequate warning to protect herself as she was going into this type of environment,” he said.

But Jones said such cases would be tough for the employer too. “I would be concerned if I sent an employee to a high risk region,” he said. “If that claim gets in front of a jury, you’re going to be looking at a very sympathetic plaintiff.”

Reuters reported last week that several international airlines are allowing flight crew members who are or may become pregnant to request reassignment to routes that avoid Zika-affected areas.

A spokeswoman for one of the airlines, American, declined to comment on possible legal liability requiring such travel could have created, saying the company’s policy was motivated by concern for employees’ well-being.

United and Delta, which have also offered to reassign their employees, could not immediately be reached.

(Reporting By Brendan Pierson in New York, Editing by Anthony Lin and Lisa Girion)

View the original article here.