“In my darker hours when I’m sleeping at night, that’s where I go.” Those are words from Eric Blank, senior director for public health systems at the Association of Public Health Laboratories (APHL), talking about the enormous difficulties that public health labs faced in confronting the 2009 H1N1 flu pandemic. Now he fears that without emergency federal funds and in the face of new funding cuts, Zika virus will force the nation’s critical public health lab network into that same scenario — or into something even worse.
“(Public health labs) know what they need and when they need it and yet it never materializes in that fashion,” Blank told me. “They have to make do and they’re expected to make do. …This is just the latest piece of erosion in building preparedness and in building the capacity to respond. I think we’ll see some more fracture this time and it may have some serious consequences.”
With mosquito season upon us, public health labs and state and local public health agencies are racing to get ready for Zika virus and adjust to new funding cuts. You read that right — funding cuts. Because ruling members of Congress have refused to grant President Obama’s request for $1.9 billion in emergency Zika funding, which Obama made back in February based on recommendations from the scientific and public health community, the Centers for Disease Control and Prevention has been forced to redirect more than $44 million in Public Health Emergency Preparedness (PHEP) funds away from state and local health departments and toward national Zika response. (In fact, Congress just left for vacation without settling the Zika funding question.) Shifting those PHEP funds means state and local public health is now losing some of the critical resources it needs to respond to Zika — and any other public health emergency that pops up this summer — at the community level.
“We’re talking about immediate staff losses, immediate reductions in buying supplies, the elimination of programs related to community outreach,” Oscar Alleyne, senior advisor of public health programs at the National Association of County and City Health Officials (NACCHO), told me about the funding shift. “The reality is that the loss of these funds is essentially handicapping the system and making it unable to run the race against (Zika) and other threats we see on the horizon.”
Last week, NACCHO, APHL, the Association of State and Territorial Health Officials, and the Council of State and Territorial Epidemiologists released two new reports on the consequences of the PHEP funding shift. Based on survey responses from health department workers, researchers found that 77 percent of state health department respondents and 75 percent of local health department respondents said “community preparedness” will be most negatively impacted by the funding shift. That means scenario planning and training exercises will be curtailed or eliminated, volunteer recruitment and training will slow, and community partnerships will be compromised. Also, more than 70 percent of state respondents said they expect functional preparedness programs — including disease surveillance, epidemiology, lab services and mosquito control — to be negatively affected. Public health labs may be forced to delay or drop new equipment purchases and put off scheduled equipment maintenance.
State and local respondents also reported that the PHEP redirect will likely result in staff cuts — and those agencies have yet to regain the staff losses they experienced during the Great Recession. More than 60 percent of local health department respondents said they expect to lose at least one preparedness staff member.
Specifically in regard to Zika, state and local health leaders said the PHEP cuts will hurt their capacity to adequately respond to and control the virus once it gains a foothold in the U.S. PHEP funding cuts, respondents say, will negatively affect public health’s capacity to identify local outbreaks, control and stop disease transmission, and provide staff trainings and exercises. Here are just a few survey respondent quotes from the reports:
“The states are the frontline of response to Zika and all other emerging infectious diseases. Taking money from the states to supplement federal activities is counterproductive. The states actually need more funding to help with response/mitigation activities.”
“The practice of taking already limited and critical preparedness funding from state and local jurisdictions, many of whom this represents the only funding they get, is an extremely dangerous precedent. […] As this funding diminishes, […] our ability to be pro-active decreases, requiring us to become more and more reactive. This approach will ultimately be far more expensive than the alternative.”
Zika response in our jurisdiction requires an increase in our baseline activity. This would be difficult with level funding, but is made exponentially more difficult when coupled with a funding reduction. The exact impacts of this have yet to be seen, but these cuts will negatively impact our ability to advance Zika preparedness and response.”
Noting that the PHEP funding redirect is a result of CDC being “between a rock and a hard place,” Peter Kyriacopoulos, senior director for public policy at APHL, said the amount of Zika testing happening right now at public health labs is already huge and growing. For example, when I spoke with Kyriacopoulos last week, he said the New York City public health lab had already completed Zika testing for 3,000 patients. (Keep in mind that’s just one lab in one city). His colleague Blank noted that Puerto Rico is now home to about 30,000 pregnant women — that’s about 100,000 Zika tests in Puerto Rico alone if all pregnant women were monitored according to current guidelines.
“These kinds of numbers could overwhelm the public health lab system’s ability to do testing in a timely fashion,” Blank said.
There are currently two lab tests for Zika. One is known as a PCR and that’s used for patients who are still within a seven-day window of the initial onset of symptoms. Right now, both public health labs and some private labs can conduct the PCR. The other is serologic testing, which is used for asymptomatic patients or patients in the late stages of Zika. Only public health and military labs can do the serologic testing, which is much more complicated. Blank noted that up to 60 PCR tests can be processed in a day, whereas serological testing has a throughput of less than a dozen per day.
And even when and if emergency Zika funding comes through, the late timing will still put public health systems and labs in a bind. For instance, Blank noted that people don’t just walk off the street capable of doing this kind of lab work — “we’re on the verge of having a busy season and we don’t have trained and ready staff available,” he added. To cope with these kinds of shortfalls, Kyriacopoulos said APHL is working to gauge the surge capacity of labs in states at low risk for Zika, with the hope that they might be able to assist high-risk states. APHL is also calling on CDC to expand the allowable extraction platforms that labs can use for Zika testing. In other words, this would allow labs to make full use of the equipment already available.
Still, both Blank and Kyriacopoulos said the emergency Zika funding that Congress has failed to provide is vital.
“It’s a very fine line that holds this system together and we’ve been very fortunate that we’ve had public health emergencies in a sequential manner,” Kyriacopoulos told me. “But if they begin happening simultaneously…like if we have a measles outbreak or a food-borne illness outbreak, we’re going to be in a world of hurt. It’s the same people in the same labs who are responsible for this with the same amount of money.”
Alleyne at NACCHO noted that as with any emergency, “public health workers will do whatever it takes” to respond to Zika. However, he said the PHEP funding shift and the lack of emergency funds will make it much more difficult for public health to tackle the complexity of Zika, which includes raising community and health care provider awareness, coordinating mosquito control and surveillance, tracking and investigating disease outbreaks, and so, so much more. And the Zika threat is complicated even more by its ability to infect people through sexual contact as well as the need to prepare health and social support systems for babies born with severe brain abnormalities.
And throughout all of the Zika response, public health still has to maintain all of its other responsibilities and activities that keep our communities healthy and safe every, single day.
“If our fundamental security blanket is not being supported through a lack of funding, then yes, any infectious disease that comes could totally inundate our health system,” Alleyne said. “Yes, we should be scared. The ability to fight any and all diseases and any weakening of that infrastructure is cause of concern.”
According to CDC, 157 pregnant women in the U.S. and 122 in U.S. territories have laboratory evidence of possible Zika infection. Just yesterday, CDC Director Tom Frieden addressed reporters at the National Press Club in D.C., saying:
Imagine that you’re standing by and you see someone drowning, and you have the ability to stop them from drowning, but you can’t. Now, multiply that by a thousand or 100,000. That’s what it feels like, to know how to change the course of an epidemic and not be able to do it, for any reason, because of challenges in implementation or funding or administrative details, the challenges of working in partnership with other organizations. Right now, the current crisis is Zika. We need a robust response to protect American women and reduce to the greatest extent humanly possible the number of families affected. We don’t know who those children will be. We don’t know where they will grow up. But anything we don’t do now, we will regret not having done later. And if we don’t take this opportunity to learn the lessons and establish some sort of facility whereby we can respond immediately and surge in when there’s a problem, we won’t be fully prepared for the next emergency. And we know there will be a next emergency.
To download a copy of the PHEP funding cut report, visit NACCHO. To learn more about public health labs’ response to Zika, visit APHL. To send a message to your member of Congress demanding action on emergency Zika funding, use this easy template from the American Public Health Association.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for nearly 15 years.