COVID-19

Lessons from Zika in the Era of COVID-19

By CHADI NABHAN, MD, MBA, FACP

If you are a soccer fan, watching the FIFA World Cup is a ritual that you don’t ever violate. Brazilians, arguably more than any other fans in the world, live and breathe soccer—and they are always expected to be a legitimate contender to win it all. Their expectations are magnified when they are the host country, which was the case in 2014. Not only did the Germans destroy Brazilian World Cup dreams, but less than a year after a humiliating loss on their turf, Brazilians began dealing with another devastating blow: a viral epidemic. Zika left the country scrambling to understand how to manage the devastation caused by the virus and grappling with conspiracies theories of whether the virus was linked to the tourism brought by hosting the FIFA World Cup.

How did I become so interested in what happened in Brazil five years ago? Well, social distancing and being mostly at home in the era of COVID-19 seems to energize reflection. Watching politicians on TV networks blaming each other and struggling to appear more knowledgeable than scientists makes me marvel at the hubris. My mind took me back to several prior epidemics that we encountered from Swine Flu to Ebola, and I couldn’t help but think about the lessons lost. What did we miss in these previous crises to land us in this current state where Zoom is your best friend and you are more interested in commenting on tweets than doing a peer-review? One cannot help but wonder what is so different about this coronavirus that it has paralyzed the globe.

I decided to take a deep dive into the Zika epidemic in a hopeful effort to better understand the present public health crisis. I started by reading Zika: The Emerging Epidemic, by Donald G. McNeil Jr, who also covers global epidemics for the New York Times. The book is a fascinating read and offers illuminating parallels to the current failings we are seeing with national and global health protection agencies during the COVID-19 pandemic.

In May 2015 when Brazil was facing the Zika epidemic, the rest of the world was watching as Brazilian mothers grieved, holding babies who had chubby cheeks and big eyes with tiny heads. Something was clearly wrong. It turns out that mothers who conceived these babies in various cities of northeast Brazil had a mysterious disease nine months prior to delivery. They suffered from headaches, rash, and fever, but the symptoms abated on their own. The disease had vague symptoms which reminded Brazilians of Dengue fever. However, many did not consider those symptoms to be serious until the babies arrived with birth defects called microcephaly. Only then did physicians recognize that this “mysterious illness” was harmful. It turns out the mothers were exposed to Zika, a virus transmitted via a mosquito named Aedes Aegypti; it crosses the placenta and affects babies.

How did Zika arrive in Brazil? Theories around the previous year’s World Cup abounded.In March 2016, epidemiologists were able to estimate that the virus was in Brazil in mid to late 2013; this was accomplished using genetic sequencing and a “molecular backward clock” to determine how fast the virus had mutated. With this timeline, the 2014 FIFA World Cup was ruled out as the event leading to Zika’s presence in Brazil. The new suspect was the Federation Cup that took place in June 2013 when Tahiti participated in the tournament. The virus was first discovered in Uganda in 1947 and surfaced outside of Africa for the first time in 2007 in the Caroline Islands. It then appeared in Tahiti in 2013 before arriving in Brazil in 2015. Brazilians were trying to explain how the virus was transmitted to their country given the geographic distance from Africa and the Caroline Islands. Uncertainty about the disease grew, which led to concerns around whether the 2016 Rio Olympics were at risk. Sound familiar? Whoever said history repeats itself was correct: the Tokyo 2020 Olympics have been postponed for a year due to COVID-19.

McNeil describes receiving an unsolicited call from Dr. Scott Weaver in October 2015; he the scientific director of the University of Texas Medical Branch and wanted to discuss the Zika virus epidemic. Dr. Weaver shared his worries, especially since the illness was preceded by a neurologic syndrome called Guillain-Barré. He was also concerned that Zika would come to the US, although he did not think it would be a major health crisis. Two months after this phone call, Brazil declared a state of emergency with more than 2,400 babies suffering from microcephalic heads.

As I read the book, I couldn’t help but make comparisons between then and now. COVID-19 and Zika both emerged from outside the US—from China and Brazil respectively. I wondered how the CDC reacted to the Zika threat in 2015-2016 and how it differed from the reaction to COVID-19. Maybe the CDC’s approach would explain how little the US suffered when it came to Zika.

The author claims that the CDC had little information, if any, on Zika despite the emergency declaration by Brazil. He took it upon himself to contact an Italian doctor he knew who happened to reside in Brazil. The doctor confirmed that it was a “big mess and a tragedy”. The affirmation from a trusted source was the impetus the author needed to contact Tom Skinner, Chief Spokesman of Dr. Thomas Frieden, the CDC director at that time. The author was hoping to get answers to questions Americans may have on this virus. The CDC website indicated that some Americans could bring the virus back home, resulting in stateside outbreaks; however, there was no additional information or answers to burning questions that Americans needed. McNeil inquired how Americans should deal with travel, pregnancy, which countries to avoid, how to handle the upcoming Olympics, and other practical questions. Tom Skinner referred him to Dr. Erin Staples, who was vague in her answers.

Essentially, the CDC had no special advice to pregnant women nor guidance regarding the Olympics. If recommendations were provided, they were changing constantly and very confusing. The CDC’s response to the Zika epidemic feels like a mirror image of their response to our current COVID-19 pandemic: an abject lack of coordinated and purposeful communication.

By January 2016, 12 cases in the US were confirmed. Still, nothing from the CDC. By mid-January, reports of autopsies on 4 Brazilian babies surfaced on the web and caught McNeil’s attention. Mothers of the 4 babies all had Zika. When McNeil inquired about a travel warning, he was given the cold shoulder and told the CDC was still “discussing recommendations”! In his own words, the author described January 15th, 2016 as a “circus” as the CDC announced a press conference at noon, then cancelled it, and then kept changing the hour the meeting would be held. The press conference started at 7pm that evening and the agency announced an interim travel guidance. One of the CDC physicians described Zika as a “fairly serious problem”.

What about the World Health Organization (WHO)? It turns out the WHO despises using the word “emergency” and reverts to using “Public Health Emergency of International Concern,” or PHEIC for brevity. On February 1st, 2016, the WHO convened a committee in Geneva, which was held in privacy given that unpublished data were going to be shared and discussed. The WHO Director General, Dr. Margaret Chan, declared a PHEIC after the meeting—but she worded the recommendations carefully, stating that the emergency was not over the spread of Zika itself, but over the possibility that Zika caused microcephaly; the WHO did not recommend any travel restrictions. The WHO declared Zika an epidemic rather than a pandemic, based on how the two are defined. The definition appears to have little to do with the gravity of the illness, but more so with the novelty of the virus and whether it is spread worldwide. Since Zika was discovered in 1947 and it was mainly in Brazil, it can’t be a pandemic. In fact, even on March 1st, 2020, the WHO still did not call COVID-19 a pandemic. We all know how that has changed since.

The book provides copious examples of CDC and WHO ineptitude in handling the Zika epidemic; examples that I can’t summarize in one article.  I encourage you to read McNeil’s book to understand the damage done to the general public with delayed action and scant understanding of disease.

Fast forward to 2020. Every reader of this article can relate to how vague the CDC recommendations have been, the anemic response by the WHO, and all the missed opportunities to intervene. We’ve been plagued by indecision and mixed messaging on everything from who should wear masks and which masks to use, to who should be tested and when and whether we continue shelter in place or open up the country. Many questions why we didn’t have a travel ban early on. Why didn’t we close airports sooner? Why are we not ramping up testing? Why did it take weeks before recommending masks for all when in public? Why are some beaches in Florida still open? Need I go on???

Reading McNeil’s account of Zika confirmed to me that relying on agencies such as the CDC and the WHO is not reassuring. The weak response to Zika was a harbinger of the present crisis. Both agencies failed us before, and they are failing us now. Frankly, it’s ironic to watch the former CDC director, who poorly handled Zika, opine on the right way to deal with COVID-19. I don’t have a clear explanation as to why Zika did not have much of an impact on the US public, but Frieden deserves no credit for that stroke of luck.

The WHO and CDC reaction to the Zika epidemic should have been a lesson. Unfortunately, we failed to learn from the mistakes of the past in handling today’s pandemic. Unless there is a fundamental change in how the WHO and CDC conduct their roles in the public health response, history will repeat itself. My hope is that future pandemics won’t be as hard and painful as COVID-19 has been, but we can all agree that there will be a future pandemic. Next time let’s learn from our mistakes.

Chadi Nabhan (@chadinabhanis a hematologist and oncologist in Chicago whose interests include lymphomas, healthcare delivery, strategy, and business of healthcare.

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