Sandman & Lanard On Zika Risk Communications

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When it comes to designing effective risk communications, Dr. Peter Sandman & Dr. Jody Lanard are about as good as it gets – which is why their services have been used by corporations, organizations, and agencies around the globe – often in the midst of a crisis.

Their website is an invaluable repository of risk management advice, that quite frankly, should be second home for anyone involved in public relations or risk communications.

I’ve featured their writings more than a dozen times over the past decade, and when they see something amiss, they are never hesitant to point it out.  A few examples over the years:

CIDRAP Commentary: Sandman & Lanard On Ebola Crisis Communications Lessons

Sandman & Lanard On Ebola & Failures Of Imagination

NPR: Jody Lanard On Addressing Ebola Fears

Sandman & Lanard: Ebola Risk Communications

As seems to be happening with increasingly frequency in this 21st century, the world is faced with another new, highly uncertain, public health threat in the Zika virus. Its future course, like that of a CAT 5 hurricane lumbering far out to sea, teeters somewhere between fizzling out and making a devastating landfall.

No one - not the CDC, not the WHO, and certainly not this humble blogger - knows how this latest EID threat will play out. 

And like cadets taking the Kobayashi Maru test of Star Trek lore, public health agencies tasked with warning the public and preparing for Zika's arrival and impact are faced with a virtual no-win scenario.

Already, even before the full extent of Zika's impact is known, there are conflicting views over whether the CDC & WHO have oversold, or undersold, the threat.

Weighing in on all of this today are Peter Sandman and Jody Lanard in a long form essay that answers questions regarding the messaging from public health agencies on Zika's threat. While they find much to praise, they warn on some potential stumbling blocks ahead.


Follow the link for an illuminating read:

Zika Risk Communication: WHO and CDC Are Doing a Mostly Excellent Job So Far

by Peter M. Sandman and Jody Lanard

(a January 31, 2016 email in response to a query
from Faye Flam of Bloomberg View)
Faye Flam’s February 1 article drew from this email.

Question from Faye Flam: In the case of Ebola, some public health officials expressed great certainty about the likely spread of the virus, though there were considerable unknowns. With Zika, again, are there unknowns that have been glossed over? Could the public health community be more straightforward with the press about the unknowns and the uncertainties?

Top U.S. public health officials have been extremely straightforward about Zika unknowns and uncertainties, calibrating their statements to convey their own levels of uncertainty to the public without overstatement or understatement, and without overconfidence.

CDC is doing spectacularly good uncertainty risk communication. The goal should be to create the same level of uncertainty in the audience as in the source. CDC’s Anne Schuchat and Lyle Petersen and NIAID Director Anthony Fauci are carefully conveying their own levels of uncertainty, neither overstating nor understating what is known and unknown about Zika.

And mainstream science reporters seem to be capturing that uncertainty pretty well in how they are quoting and paraphrasing these expert officials.  

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Transcript & Audio For Today's CDC Zika Briefing

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I know many of my readers were not able to listen to today's CDC press briefing on Zika, so I'm happy to report a preliminary transcript and the audio have been quickly posted on the CDC's Media Center website.

Transcript for CDC Telebriefing: Zika

 Press Briefing Transcript

Tuesday, February 5, 2016 at 4:00 pm E.T.

• Audio recording[MP3, 8.5 MB]

Please Note:This transcript is not edited and may contain errors.

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WHO Zika SitRep - February 5th

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The World Health Organization has published a 6 page PFD SitRep report on Zika' spread, and concurrent increases in Microcephaly, and Guillain-Barré syndrome in the Americas.

Download the full situation report HERE .   I've only excepted the summary.

Summary

Neurological syndrome and congenital anomalies

• Read the full situation report
  5 February 2016

• An Emergency Committee was convened by the Director-General under the International Health Regulations (2005) on 1 February 2016. Following the advice of the Committee, the Director-General announced the recent cluster of microcephaly and other neurologic disorders reported in Brazil to be a Public Health Emergency of International Concern.
• The Emergency Committee agreed that a causal relationship between Zika infection during pregnancy and microcephaly is strongly suspected, though not yet scientifically proven. All experts agreed on the urgent need to coordinate international efforts to investigate and understand this relationship better.
• Between January 2014 and 5 February 2016, a total of 33 countries have reported autochthonous circulation of Zika virus. There is also indirect evidence of local transmission in 6 additional countries.
• The geographical distribution of Zika virus has been steadily increasing since it was first detected in the Americas in 2015. Further spread to countries within the geographical range of competent disease vectors — Aedes mosquitoes — is considered likely.
• Seven countries have reported an increase in the incidence of cases of microcephaly and/or Guillain-Barré syndrome concomitantly with a Zika virus outbreak.
• The global prevention and control strategy launched by WHO is based on surveillance, response activities, and research.

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CDC Issues Updated Guidelines For Preventing Sexual Transmission Of Zika

Credit CDC

 



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CDC Director Thomas Frieden held an hour long press conference this morning (a transcript & audio should be  posted on the CDC site later) to announce two new sets of guidance on the Zika virus. 

While there is still much that isn't known about the Zika virus and its effects on human health, Dr. Frieden noted in his opening that with each passing day, the linkage between Zika and microcephaly becomes stronger. 

Full details are available in two MMWR Early releases, but we've a summary from the CDC as well.

• Interim Guidelines for Prevention of Sexual Transmission of Zika Virus — United States, 2016 FEBRUARY 5, 2016
  CDC has updated its interim guidelines for U.S. health care providers caring for pregnant women during a Zika virus outbreak. This update also expands guidance to women of reproductive age who reside in areas with ongoing Zika virus transmission.
  
  
• Update: Interim Guidelines for Health Care Providers Caring for Pregnant Women and Women of Reproductive Age with Possible Zika Virus Exposure — United States, 2016 FEBRUARY 5, 2016
  Sexual transmission of Zika virus is possible, and is of particular concern during pregnancy. Current information about possible sexual transmission of Zika is based on reports of three cases. This report provides interim recommendations for the prevention of sexual transmission of Zika virus.
  

CDC issues Interim Guidelines for Preventing Sexual Transmission of Zika Virus and Updated Interim Guidelines for Health Care Providers Caring for Pregnant Women and Women of Reproductive Age with Possible Zika Virus Exposure

Media Statement

Embargoed Until: Friday, February 5, 2016, 11:00am ESTContact: Media Relations, (404) 639-3286

CDC has issued new interim guidance on preventing sexual transmission of Zika virus after confirming through laboratory testing, in collaboration with Dallas County Health and Human Services, the first case of Zika virus infection in a non-traveler in the continental United States during this outbreak.

Although sexual transmission of Zika virus infection is possible, mosquito bites remain the primary way that Zika virus is transmitted. Because there currently is no vaccine or treatment for Zika virus, the best way to avoid Zika virus infection is to prevent mosquito bites.

Based on what we know now, CDC is issuing interim recommendations to prevent sexual transmission of Zika virus. To date, there have been no reports of sexual transmission of Zika virus from infected women to their sex partners. CDC expects to update its interim guidance as new information becomes available.

New recommendations for pregnant women, and men with pregnant sex partners who live in or have traveled to Zika-affected areas:

• Pregnant women and their male sex partners should discuss the male partner’s potential exposures and history of Zika-like illness with the pregnant woman’s health care provider (http://www.cdc.gov/zika/symptoms/). Providers should consult CDC’s guidelines for evaluation and testing of pregnant women.
• Men with a pregnant sex partner who reside in or have traveled to an area of active Zika virus transmission and their pregnant sex partners should consistently and correctly use condoms during sex (vaginal, anal, or oral) or abstain from sexual activity for the duration of the pregnancy. Consistent and correct use of latex condoms reduces the risk of sexual transmission of many infections, including those caused by other viruses.

New recommendations for non-pregnant women, and men with non-pregnant sexual partners who live in or have traveled to Zika-affected areas:

• Couples in which a man resides in or has traveled to an area of active Zika virus transmission who are concerned about sexual transmission of Zika virus may consider using condoms consistently and correctly during sex or abstaining from sexual activity.  
• Couples may consider several factors when making this complex and personal decision to abstain or use condoms:
  • Zika virus illness is usually mild. An estimated 4 out of 5 people infected never have symptoms; when symptoms occur they may last from several days to one week.
  • The risk of Zika infection depends on how long and how much a person has been exposed to infected mosquitoes, and the steps taken to prevent mosquito bites while in an affected area.
• The science is not clear on how long the risk should be avoided. Research is now underway to answer this question as soon as possible. If you are trying to get pregnant, you may consider testing in discussion with your health care provider.

Updated interim guidelines for healthcare providers

CDC also has updated its interim guidance for healthcare providers in the United States caring for pregnant women and women of reproductive age with possible Zika virus exposure.

The updated guidelines recommend that pregnant women without symptoms of Zika virus disease can be offered testing 2 to 12 weeks after returning from areas with ongoing Zika virus transmission.

New recommendations for women who reside in areas with ongoing Zika virus transmission, both pregnant women and women of reproductive age, include the following:

• For pregnant women experiencing symptoms consistent with Zika virus disease, testing is recommended at the time of illness.
• For pregnant women not experiencing symptoms consistent with Zika virus disease, testing is recommended when women begin prenatal care. Follow-up testing around the middle of the second trimester of pregnancy is also recommended, because of an ongoing risk of Zika virus exposure. Pregnant women should receive routine prenatal care, including an ultrasound during the second trimester of pregnancy. An additional ultrasound may be performed at the discretion of the health care provider.
• For women of reproductive age, healthcare providers should discuss strategies to prevent unintended pregnancy, including counseling on family planning and the correct and consistent use of effective contraceptive methods, in the context of the potential risks of Zika virus transmission.
• Local health officials will need to determine when to implement testing recommendations for pregnant women without symptoms based on information about local levels of Zika virus transmission and local laboratory capacity.

All travelers to or residents of areas with ongoing Zika virus transmission should strictly follow measures to prevent mosquito bites.

CDC continues to work with other public health officials to monitor for ongoing Zika virus‎ transmission. CDC has issued travel alerts (Level 2-Practice Enhanced Precautions) for people traveling to regions and certain countries where Zika virus transmission is ongoing. For a full list of affected countries/regions, check this site regularly: http://www.cdc.gov/zika/geo/index.html.

CDC guidance on Zika virus, its transmission, treatment, and response to the outbreak will continue to be updated as more becomes known.  

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FIOCRUZ: Statement On Detection Of Zika Virus In Saliva and Urine

UPDATED (Feb 6th 0700hrs): Illustrating the risks of proclaiming `Eureka!',  Dr. Ian Mackay on his VDU blog has turned up at least one other instance of live Zika virus detected in urine in Urine found to contain infectious Zika virus...again...

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It isn't news that traces of the Zika virus can be found in urine or saliva, as viral RNA has been detected using RT-PCR testing since 2014 (see Detection of Zika virus in saliva), What hasn't been demonstrated - until now - is the presence of live Zika virus in these bodily fluids. 

The news hitting the AP and Reuters this morning has been the confirmation of live virus detection in saliva and urine by FIOCRUZ, Brazil's leading scientific research institute. 

While the implications of this finding are not yet clear, this will raise new questions about the routes of transmission of the virus from human-to-human.


Excerpts from the FIOCRUZ (Fundação Oswaldo Cruz) statement follows:

(translated)

Fiocruz detects the presence of zika virus with potential for infection in saliva and urine

Oswaldo Cruz Foundation (Fiocruz)

Foundation's pioneering study Oswaldo Cruz (Fiocruz), a body linked to the Ministry of Health, found the presence of active virus zika (with potential to cause infection) in saliva and urine samples. The unpublished evidence, which suggests the need to investigate the relevance of these alternative routes of virus transmission was observed by Flavivirus of Molecular Biology Laboratory of the Instituto Oswaldo Cruz (IOC / Fiocruz).

The studies were led by researcher Myrna Bonaldo, head of the Laboratory, in collaboration with infectious Patricia Brazil, the National Institute of Infectious Diseases Evandro Chagas (INI / Fiocruz). Samples were analyzed regarding two patients and samples were taken during the presentation of symptoms compatible with zika virus. Aliquots of the samples were placed in contact with Vero cells, which are widely used in studies of viral activity in the case of the flavivirus family, which belong to the Zika virus, dengue and yellow fever, among others.

Scientists have observed the CPE caused the cells: we observed the destruction or damage of cells, which proves the viral activity. The presence of the genetic material of zika virus was confirmed by RT-PCR in Real Time. It was also performed the partial sequencing of the virus genome. Laboratory diagnosis ruled out the presence of dengue virus and chikungunya - for these analyzes, we used the NAT Kit Discriminatory for Dengue, Chikungunya and Zika recently developed by Fiocruz. 

"It was known that the virus could be present in both urine and saliva. This is the first time we've demonstrated that the virus is active, ie, with the potential to cause infection, which opens new paradigms for understanding the transmission routes of the Zika virus. That answers an important question, however, the understanding of the epidemiological relevance of these potential routes of infection further studies "lies Myrna Bonaldo.

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The Lancet: Indentification Of Zika Virus Vectors

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The accepted wisdom - which is echoed in virtually every Zika story - is that the Aedes Aegypti mosquito is the primary vector for the virus. The Aedes Albopictus mosquito is also a suspected Zika vector, but its actual impact on the virus's spread is still unknown.

There are, however, more than 3,500 species of mosquito around the globe, and as least 175 can be found in the United States - including the two Aedes vectors (see map above) - and most have never been tested to see whether they can transmit Zika. 

A little over a week ago, in FIOCRUZ Researchers Investigate Other Possible Zika Mosquito Vectors, we looked at ongoing research looking to see if the Culex mosquito (common in the U.S. & in South America) might carry and transmit the Zika virus, but answers are still likely weeks away.


Last night The Lancet published a comment by Constância F J Ayres, an entomologist and research coordinator of the Culex/Zika research project at FIOCRUZ (Fundação Oswaldo Cruz), who outlines the lack of data on the Zika virus vectors and warns:

To assume that the main vector is A aegypti in areas in which other mosquito species coexist is naive, and could be catastrophic if other species are found to have important roles in Zika virus transmission.

The full comment (which is short) may be read at:

Identification of Zika virus vectors and implications for control

Constância F J Ayres

Published Online: 04 February 2016

DOI: http://dx.doi.org/10.1016/S1473-3099(16)00073-6

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UK: Aircraft Disinsection Ordered For Zika

Scheduled airline traffic around the world, circa June 2009 – Credit Wikipedia

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Although infected travelers are the most likely way for Zika (or Dengue, CHKV, or malaria) to make it from endemic regions to North America or Europe, aircraft and ships often carry unauthorized passengers; stowaway mosquitoes.


Up until now, `Airport Malaria'  has been the biggest concern, and the CDC even has a definition for it on their Malaria Transmission in the United States web page:

"Airport" Malaria

"Airport" malaria refers to malaria caused by infected mosquitoes that are transported rapidly by aircraft from a malaria-endemic country to a non-endemic country. If the local conditions allow their survival, they can bite local residents who can thus acquire malaria without having traveled abroad

In 2008, the American Society of Tropical Medicine and Hygiene warned:

Warmer climate changes in major U.S. cities with a large presence of international air traffic, such as New York and Los Angeles, seem to have created a more welcoming environment where these infected mosquitoes can survive. It begins with a mosquito that is transported during an international flight from a malaria-endemic region. Once the infected female mosquito leaves the aircraft, it can survive long enough to seek blood meals and transmit the disease to other humans within the airport. This type of international transmission creates an increased possibility for the reintroduction of not just malaria, but other detrimental diseases such as dengue and Chikungunya fever, into areas where they are not normally found.

Today the UK has announced that all aircraft inbound from Zika endemic regions will be required to undergo disinsection, a procedure which is currently done for flights from regions where malarial diseases are endemic.

 Planes returning from Zika areas to be sprayed with insecticide

From: Department of Health, Department for Transport and Public Health England

First published: 5 February 2016

All aircraft returning to the UK from countries currently affected by active Zika virus transmission will be sprayed with insecticide as part of a comprehensive government response to the disease.

On Monday, the World Health Organisation (WHO) declared the issue of microcephaly - which may be linked to Zika - a public health emergency of international concern.

As a precautionary measure, the government is asking airlines to ensure that disinsection (spraying with insecticide) takes place on all flights to the UK from countries with confirmed transmission of Zika.

Disinsection involves spraying a simple insecticide inside the aircraft to reduce the risk of passengers being bitten by any mosquitoes that could have entered the aircraft. It already occurs on the majority of flights from the region as a precaution against malaria.

The move is consistent with advice from WHO Europe. The type of mosquito that transmits the virus is extremely unlikely to survive and breed here given the lower temperatures in the UK.

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This practice, which is likely to become more common as Zika spreads, is not without its controversy. Although WHO weighed in on its safety 20 years ago (see below), some passengers have reported temporary ill effects or discomfort from the exposure. 

The choice, however, is to either to spray flights or allow potentially infected mosquitoes free international travel, with complementary in-flight blood meals thrown in as a bonus. 

The United States Transportation Department explains the procedures and the law:

Aircraft Disinsection Requirements
 
Overview

Disinsection is permitted under international law in order to protect public health, agriculture and the environment. The World Health Organization and the International Civil Aviation Organization stipulate two approaches for aircraft disinsection--either spray the aircraft cabin, with an aerosolized insecticide, while passengers are on board or treat the aircraft's interior surfaces with a residual insecticide (residual method) while passengers are not on board. Panama and American Samoa have adopted a third method, in which aircraft are sprayed with an aerosolized insecticide while passengers are not on board.

Although the Report of the Informal Consultation on Aircraft Disinsection sponsored by the World Health Organization (November 6-10, 1995) concluded that aircraft disinsection, if performed appropriately, would not present a risk to human health, the report also noted that some individuals may experience transient discomfort following aircraft disinsection by aerosol application.

Although few countries now require that aircraft be disinsected, most countries reserve the right to do so, and, as such, could impose a disinsection requirement should they perceive a threat to their public health, agriculture or environment. Accordingly, travelers are advised to check with their travel agent or airline reservations agent when booking flights. Listed below are representatives of airlines who are knowledgeable on disinsection requirements. 

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The UK appears to be the first major country to order the spraying of all flights from Zika affected regions, but other nations are no doubt considering similar steps.

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