The emergency response to Zika virus disease required coordinated efforts and heightened
collaboration among federal, state, local, and territorial public health jurisdictions.
CDC activated its Emergency Operations Center on January 21, 2016, with seven task
forces to support the national response. The State Coordination Task Force, which
functions as a liaison between jurisdictions and federal operations during a response,
coordinated the development of CDC Guidelines for Development of State and Local Risk-based
Zika Action Plans, which included a Zika Preparedness Checklist (
1
). The checklist summarized recommendations covering topics from the seven task forces.
In July 2016, CDC’s Office of Public Health Preparedness and Response (OPHPR) awarded
$25 million in supplemental funding to 53 jurisdictions (41 states, eight territories,
and four metropolitan areas) to support Zika preparedness and response activities.
In December 2016, CDC awarded an additional $25 million to 21 of the 53 jurisdictions
at the greatest risk for seeing Zika in their communities based on the presence of
the mosquito responsible for spreading Zika, history of local transmission, or a high
volume of travelers from Zika-affected areas. The additional $25 million was part
of the $350 million in Zika supplemental funding provided to CDC by Congress in 2016*
(
2
,
3
). Funded jurisdictions reported progress through the checklist at five quarterly
points throughout the response. Data were analyzed to assess planning and response
activities. Among the 53 jurisdictions, the percentage that reported having a Zika
virus readiness, response, and recovery plan increased from 26% in June 2016 to 64%
in July 2017. Overall, Zika planning and response activities increased among jurisdictions
from June 2016 to July 2017. The recent Zika virus outbreak underscores the importance
of strengthening state, local, and territorial health department capacity for rapid
response to emerging threats.
Jurisdictions selected to receive supplemental funding for Zika preparedness and response
were chosen based on the estimated geographic range of the two mosquito vectors known
to carry and likely transmit Zika virus (i.e., Aedes albopictus and Aedes aegypti)
in the United States in 2016 (
3
). Funded jurisdictions included 41 states,
†
eight territories (American Samoa, Federated States of Micronesia, Guam, Marshall
Islands, Northern Mariana Islands, Palau, Puerto Rico, and U.S. Virgin Islands) and
four local jurisdictions (Chicago, Los Angeles County, New York City, and the District
of Columbia).
§
In April 2016, the Zika Preparedness Guidance document, based on the CDC guidelines
(
1
), was distributed from the State Coordination Task Force to state, local, and territorial
health departments preparing to respond to potential Zika virus transmission; funded
jurisdictions were required to complete the checklist. Health department staff members
were expected to address elements in the CDC guidelines, and they were required to
submit quarterly progress on the checklist based on whether they 1) had fully completed
the actions listed; 2) had begun the actions, but had not fully implemented or completed
the actions; 3) had not started the actions; or 4) did not answer because the guidance
element was not applicable to their jurisdiction. Data were collected at baseline
in June 2016 and at the end of each quarter in October 2016, January 2017, April 2017,
and July 2017.
The checklist divided the Zika response into four phases to reflect the burden and
intensity of risk for Zika virus transmission. The pre-incident stage included phase
0 (preparedness) and phase 1 (mosquito season, but no local transmission). Phase 2
was defined by confirmed local transmission, and phase 3 by confirmed local multiperson
transmission. Respondents completed up to 112 questions depending on the presence
of capable vectors and the extent of local transmission. Questions were aggregated
within the following seven activity domains: 1) operations and planning, 2) communications
and community education, 3) vector control, 4) surveillance, 5) laboratory testing,
6) outreach to pregnant women, and 7) blood safety. For each reporting period, the
number and percentage of jurisdictions reporting activity on ≥85% of the guidance
elements (selected as the minimum indicator of Zika preparedness) was determined.
Jurisdictions with multiple confirmed cases of local mosquitoborne transmission of
Zika virus increased from three in June 2016 to seven in July 2017 (Table 1). By October
2016, all jurisdictions were reporting cases (mostly travel-related, except in the
territories, where endemic transmission was occurring) during their respective mosquito
seasons and provided responses to all guidance elements through phase 1. Ten jurisdictions
provided responses for elements in phases 2 and 3.
TABLE 1
Response phase of jurisdictions — 53 U.S. cities, states, and territories, June 2016–July
2017
Stage
Phase level
Transmission risk category
No. (%) of jurisdictions*
Jun 2016
Oct 2016
Jan 2017
Apr 2017
Jul 2017
Pre-incident
Phase 0: Preparedness
Vector present or possible in the state
53 (100)
53 (100)
53 (100)
53 (100)
53 (100)
Phase 1: Mosquito season
Aedes aegypti or Aedes albopictus mosquito biting activity or introduced travel-related
cases, or cases transmitted sexually or through other body fluids
43 (81)
53 (100)
53 (100)
53 (100)
53 (100)
Suspected/ Confirmed incident
Phase 2: Confirmed local transmission
Single, locally acquired case, or cases clustered in a single household and occurring
<2 weeks apart
3 (6)
7 (13)
10 (19)
10 (19)
10 (19)
Incident/ Response
Phase 3: Confirmed local multiperson transmission
Illness onsets ≥2 weeks apart, but within an approximately 1 mile (1.5 km) diameter
3 (6) (AS, PR, USVI)
5 (9) (AS, FL, FSM, PR, USVI)
7 (13) (AS, FL, FSM, MI, PR, TX, USVI)
7 (13) (AS, FL, FSM, MI, PR, TX, USVI)
7 (13) (AS, FL, FSM, MI, PR, TX, USVI)
Abbreviations: AS = American Samoa; FL = Florida; FSM = Federated States of Micronesia;
MI = Marshall Islands; PR = Puerto Rico; TX = Texas; USVI = U.S. Virgin Islands.
*41 U.S. states, eight territories (American Samoa, Federated States of Micronesia,
Guam, Marshall Islands, Northern Mariana Islands, Palau, Puerto Rico, and U.S. Virgin
Islands) and four local health jurisdictions (Chicago, Los Angeles County, New York
City, and the District of Columbia).
During phases 0 and 1, the percentage of 53 jurisdictions reporting activity on ≥85%
of the guidance elements ranged from 77% (operations and planning) to 98% (communications
and community education and outreach to pregnant women) (Table 2). During phases 2
and 3, the percentage of 10 jurisdictions reporting activity on ≥85% of the guidance
elements ranged from 71% (vector control and outreach to pregnant women) to 100% (operations
and planning, surveillance, laboratory testing, and blood safety).
TABLE 2
Zika planning and preparedness activities across the seven activity domains — 53 U.S.
cities, states, and territories, July 2017
Activity domains
No. of guidance elements
No. (%) of jurisdictions responding “Yes” or “In progress” to ≥85% of domain elements
Zika response phase levels 0 and 1 (53 jurisdictions)
Operations and planning
9
41 (77)
Communications and community education
14
52 (98)
Vector control
5*
47 (89)
Surveillance
17
44 (83)
Laboratory testing
10
49 (92)
Outreach to pregnant women
1†
52 (98)
Blood safety
4
40 (92)§
Zika response phase level 2 (10 jurisdictions) and phase level 3 (7 jurisdictions)
Operations and planning
8
7 (100)
Communications and community education
9
6 (86)
Vector control
6
5 (71)
Surveillance
7
7 (100)
Laboratory testing
2
7 (100)
Outreach to pregnant women
11
5 (71)
Blood safety
7
7 (100)¶
* One element was deleted from the analysis because of ambiguity in interpretation.
† One element about providing window-screening kits was deleted from the analysis
because it was not relevant to most jurisdictions.
§ Nine jurisdictions were subtracted from the denominator (seven territories do not
have blood centers, and two localities depend on their state health department to
work with blood centers).
¶ Adjusted for guidance elements that were not applicable to jurisdiction.
Jurisdictions reporting development of Zika virus readiness, response, and recovery
plans increased from 14 (26%) in June 2016 to 34 (64%) in July 2017 (Table 3). There
was an increase in the number of jurisdictions reporting updated training and educational
materials for pregnant women (outreach to pregnant women domain; from 24 [45%] to
46 [87%]), publicizing travel guidance (communications and community education domain;
from 31 [58%] to 51 [96%]), and developing state action plan for vector control (vector
control domain; from 17 [32%] to 30 [57%]).
TABLE 3
Selected Zika planning and preparedness activities — 53 cities, states, and territories,
United States, June 2016–July 2017
Selected elements within the Zika Preparedness Checklist domains
No. (%) of jurisdictions reporting fully completing the action within the activity
domain by reporting quarter
Jun 2016
Oct 2016
Jan 2017
Apr 2017
Jul 2017
1. Operations and planning
Conduct a Zika virus preparedness and response planning workshop
25 (47)
35 (66)
36 (68)
37 (70)
40 (75)
Develop a Zika virus readiness, response, and recovery plan
14 (26)
21 (40)
27 (51)
30 (57)
34 (64)
2. Communications and community education
Develop public health communications messages
21 (40)
36 (68)
39 (74)
40 (75)
41 (77)
Publicize travel guidance
31 (58)
45 (85)
49 (92)
49 (92)
51 (96)
3. Vector control
Develop a state action plan for vector control
17 (32)
26 (49)
29 (55)
30 (57)
30 (57)
Identify existing state, local, and national mosquito control resources
17 (32)
27 (51)
28 (53)
29 (55)
31 (58)
4. Surveillance
Determine procedures to identify potential or confirmed Zika virus infection
32 (60)
39 (74)
41 (77)
43 (81)
45 (85)
Establish baseline prevalence of microcephaly
25 (47)
31 (58)
35 (66)
36 (68)
35 (66)
5. Laboratory testing
Coordinate sample referral and testing with epidemiologist
48 (91)
53 (100)
53 (100)
53 (100)
53 (100)
Make available most current Zika virus testing algorithm
44 (83)
46 (87)
50 (94)
49 (92)
51 (96)
6. Outreach to pregnant women
Updated training and educational materials with information for pregnant women
24 (45)
39 (74)
45 (85)
46 (87)
46 (87)
7. Blood safety
Work with blood centers to ensure implementation of Food and Drug Administration blood
safety recommendations
25 (47)
28 (53)
38 (72)
38 (72)
40 (75)
Among the seven jurisdictions experiencing local transmission in July 2017 (American
Samoa, Florida, Federated States of Micronesia, Puerto Rico, Marshall Islands, Texas,
and the U.S. Virgin Islands), five monitored effectiveness of vector control treatments
through trapping and re-treating if mosquito numbers began to increase again (vector
control), and five had laboratory testing staff members and surge reagents in place
(laboratory testing). Similarly, six of the seven jurisdictions developed community
outreach plans to prevent sexual transmission (communications and community education),
expanded vector control efforts within areas of local transmission (vector control),
expanded surveillance and monitoring of pregnant women (surveillance), developed procedures
to follow up with Zika positive blood donors (blood safety), and identified geographic
areas for aggressive response efforts (operations and planning).
Discussion
Since May 2015, CDC has responded to reports of adverse pregnancy and birth outcomes
associated with Zika virus infection during pregnancy. Collaboration with jurisdictions
about case reports, surveillance, and registry data facilitated surveillance and increased
knowledge about the impact of Zika virus infection on pregnant women and their fetuses
and infants. According to CDC U.S. Zika Pregnancy Registry data since 2016, among
women in the United States who had laboratory evidence of possible Zika virus infection
during pregnancy, 6%–11% of fetuses or infants had evidence of Zika-associated birth
defects (
4
); among women in the U.S. territories who had laboratory evidence of possible Zika
virus infection during pregnancy, 4%–8% of fetuses or infants had birth defects potentially
related to Zika virus (
5
).
The quarterly Zika preparedness assessments facilitated active monitoring of progress
toward Zika preparedness and response activities in 53 jurisdictions and provided
situational awareness among internal and external partners, including the Zika response
leadership, professional health care associations, nonprofit organizations, academic
and research institutions, and the private sector. The checklist documented that health
departments prepared for and implemented strategies to reduce the transmission of
Zika virus. From June 2016 to July 2017, the percentage of jurisdictions reporting
full completion of actions across all domains in the Zika Preparedness Guidance increased
overall. The largest reported increases were in the following domains: operations
and planning, communications and community education, outreach to pregnant women,
and blood safety. The Zika supplemental funding, along with the funding provided through
the Public Health Emergency Preparedness cooperative agreement, supports public health
preparedness infrastructure to respond to large-scale emerging public health threats
(
6
).
The findings in this report are subject to at least two limitations. First, the data
were collected through quarterly assessments. Second, the data represent self-reported
progress on broad Zika Preparedness Guidance elements rather than objectively reviewed
specific performance measures. A more detailed assessment ascertained by independent
evaluators could potentially facilitate better planning and response actions in future
outbreaks.
The quarterly assessment findings provide objective evidence of progress toward meeting
Zika planning and preparedness goals among the 53 jurisdictions receiving supplemental
funding. As a result, the preparedness plans and strategies to reduce transmission
and adverse effects of Zika in these jurisdictions improved compared with those in
June 2016. CDC collaboration with state, local, and territorial health departments
strengthened the response to this emerging threat and demonstrated the ability of
public health departments to prepare and respond to an emerging public health event.
Summary
What is already known about this topic?
Zika virus infection can cause adverse pregnancy-related birth defects and brain abnormalities.
Local transmission of Zika virus was documented in the United States and its territories
after the spread of Zika virus in the World Health Organization’s Region of the Americas.
What is added by this report?
Among 53 jurisdictions, Zika planning and response activities increased from June
2016 to July 2017, with the largest increases in percentage of jurisdictions reporting
fully completed actions for the operations and planning, communications and community
education, outreach to pregnant women, and blood safety domains.
What are the implications for public health practice?
Zika planning, preparedness, and response activities from June 2016 to July 2017 demonstrated
the importance of collaboration between CDC and U.S. state, local, and territorial
public health departments in preparation for and response to an emerging event.