The Effects and Aftermath of Zika Virus on Latin America

The recent Zika virus pandemic brought the disease to the forefront of public health discussions in the United States and around the world. Zika’s association with birth defects prompted a global coordinated response led by the World Health Organization (WHO). Although the WHO lifted the ‘public health emergency’ designation in November 2016, concerns about the disease and its implications still remain (“Fifth Meeting”). In this paper, I will give a general overview of Zika, review the history and current state of Zika worldwide, and discuss the populations it affects, the economic and social consequences, three approaches to tackle these issues, and the specific impact Zika has on the United States.

Overview of Zika

Zika is an arbovirus and is transmitted by both mosquitos found in tropical areas and by exposure to bodily fluids (Shirley and Nataro 938-939). Individuals infected by Zika usually show no symptoms or only mild symptoms, such as fever, rash, headache, and joint pains. The main risk associated with Zika is for pregnant women who can transmit Zika to their fetus. Zika can lead to multiple negative health outcomes for pregnant women, such as birth defects, stillbirth, miscarriage, and Guillain-Barré syndrome (“Overview”).

Microcephaly, the most common congenital birth defect caused by Zika infection, can hinder the development of the child’s brain and is linked with further health problems, such as seizures, developmental delays, and intellectual disabilities (“Facts About Microcephaly”). For people affected by Guillain-Barré syndrome, their immune system attacks peripheral nerves that control muscle movement and are important for pain, temperature, and touch. It can lead to tingling in the limbs and weakness and eventually even paralysis. Some severe cases result in difficulty breathing, talking, and swallowing. These symptoms are usually short lived, but some cases can result in long-term weakness and even death (“Guillain-Barré syndrome”). It was these troubling health impacts of Zika that led to public hysteria and major public health efforts when the recent Zika pandemic was at its height.

History and Current State of Zika

Zika virus was discovered in 1947 in Uganda in a rhesus monkey. For the next 60 years, there were only 14 cases in humans, mostly in Africa and Asia. For these individuals, the infection was mild and did not last long. At the time, some researchers began to speculate that Zika could be related to negative health impacts on fetuses. Yet, there was little interest in prevention and research because it affected too little people (“One year”). The first outbreak of Zika in the 21st century occurred in 2007 in Yap Island in Micronesia with 5,000 cases. This outbreak was short and led to zero hospitalizations and deaths. Zika broke out again in 2013-2014 in French Polynesia, affecting 30,000 people but leading to zero deaths once again. In 2015, Zika was brought to Brazil, and the disease spread rapidly within the country and throughout Latin America and the Caribbean (“One year”). From January 2015 to March 2017, 754,460 suspected and laboratory-confirmed cases of Zika in the Americas were reported. Most cases (70%) came from South America, while 21% of cases were from the Caribbean, 9% from Central America, and 1% from North America (Hills, Fischer, and Petersen S868). In 2016, Zika became a nationally notifiable condition in the United States and 5,102 symptomatic cases were reported throughout the year. Local transmissions of Zika were reported in both Florida and Texas (“2016 Case Counts”). During the same time period, there were also increases in the number of cases of Zika-associated microcephaly, with 2767 confirmed cases as of March 2017 in 24 countries (Hills, Fischer, and Petersen S870).

Since 2016, the number of Zika cases has decreased in the Americas. In 2017, only 385 cases were reported in the United States (“2017 Case Counts”). In May 2017, Brazil ended its declaration of a national emergency, citing a 95% decrease in cases from January to April of 2017 (“Ministério da Saúde”). These decreasing trends are the result of huge coordinated efforts among global health organizations, local governments, and health departments. However, Zika is still a threat to certain populations.

Affected Populations

The populations that should take extra caution to protect against Zika are pregnant women, partners of pregnant women, and couples considering pregnancy. However, all travelers to areas with a high risk of Zika transmission should protect against mosquito bites and exposure to infected individuals. The Centers for Disease Control and Prevention (CDC) still strongly recommends that pregnant women avoid areas with a high risk of Zika. For partners of pregnant women and couples considering pregnancy, the CDC advises strictly following steps to protect themselves, including using EPA-registered insect repellents, covering exposed skin, and using condoms during travel and three weeks after (“There is a Risk”). The CDC also suggests that pregnant women that live in or travel to an area with a high risk of Zika should be tested for the disease throughout their pregnancy at prenatal visits (“Zika is in Your Area”). The countries that the CDC designates as having a risk of Zika span across the world, and include 30 countries in Africa, 14 in Asia, 25 in the Caribbean, 7 in Central America, 1 in North America, 6 in the Pacific Islands, and 11 in South America (“Zika Travel Information”).

Economic and Social Consequences

The economic costs of the pandemic were staggering. It is estimated that total losses to gross domestic product from 2015-2017 ranged from $7-18 billion. About 90% of these costs were due to loss of tourism and the cost associated with diagnosing patients. These are just short-term costs. The long-terms costs associated with Zika will due to significant medical costs associated with microcephaly and Guillain-Barré Syndrome and loss of participation in the workforce. The direct medical costs of microcephaly alone are $180,004 per case (“A Socio-Economic Impact” 8, 19, 30).

It is important to note that the economic impacts are not equally distributed among affected regions. Latin America and the Caribbean, the areas hardest hit by Zika, have the highest income inequality in the world, even compared to regions in Africa and Asia that have higher poverty levels. Zika has been called a “disease of poverty” because it disproportionality affects poorer populations that are already vulnerable due to lack of health infrastructure and poor sanitation. The highest short-term costs as a fraction of GDP were among the poorest countries affected, such as Haiti and Belize (“A Socio-Economic Impact” 17, 19). The higher distribution of Zika and its negative health implications in poor communities will only expand these economic inequalities. Low income individuals will face the enormous lifelong costs of microcephaly and be pushed further into poverty. This has profound, long-term social consequences, such as lower educational attainment, homelessness, higher risk of crime, and mental health problems (“The Consequences of Poverty”).

Another important social consequence of Zika is the stigma many infected individuals face. Mothers are often blamed for not better protecting their children from birth defects and are burdened with guilt. Lower-income women are less likely than higher-income women to receive information about Zika prevention and have access to family planning resources. Low-income women are also more likely to have unplanned pregnancies where they may not have taken the proper precautions to avoid infection (“A Socio-Economic Impact” 42). In fact, Latin America and the Caribbean have the highest rate of unplanned pregnancies in the world at 56% of all pregnancies (“One year”). These women face judgement from their communities because the responsibility of prevention is unfairly put solely on the women. The children born with birth defects will also likely face prejudice for the entirety of their lives.

Zika virus has also brought to light the reproductive rights of women in Latin America and the Caribbean. Many of the countries in these regions have very strict abortion laws. Approximately 97% of women of reproductive age in these regions live in a country where abortion is either restricted or completely banned. Yet, the abortion rate is still high and most abortions are done in unsafe conditions (“Abortion in Latin America”). Women in these areas that have a high risk of becoming infected are forced to continue their pregnancies, often in fear. If they do seek abortion, it is frequently in extremely unsafe conditions, leading to very serious complications and in many cases, maternal death. This has sparked international conversations on the need for more comprehensive reproductive services for women in high risk areas, increased access to prenatal diagnostic tests, less restrictive abortion laws, and greater support for women who choose to stay pregnant.

How to Address These Issues

There are three approaches to address Zika that I believe would be the most successful. These include: funding vaccine development and research, improving reproductive services, and public awareness campaigns. Currently, there is no approved vaccine for Zika virus. However, there has been significant progress and a Zika vaccine could be within sight. A trial of one vaccine showed an immune response with little to no side effects in humans. After the final dose of the vaccine, all of the study participants showed Zika-specific antibodies and 62% showed significant neutralizing antibodies against Zika. Because this was only a phase one trial, there were only 40 study participants (Tebas et al. 1-2). While the results are promising, it reveals that a lot more research needs to be done. The WHO’s lifting of the ‘public health emergency’ designation could be problematic because it could divert funding away from the development of a Zika vaccine. It is essential that efforts to find an effective vaccine in humans are continued to protect pregnant women in high risk areas and to prepare for a future widespread epidemic.

The second approach, improved reproductive services, will help women in high risk areas avoid unplanned pregnancies affected by Zika. Family planning professionals can help women understand their risk of Zika, the types of contraceptives they can use, and how they can time their pregnancies to prevent Zika from impacting their baby. One study of women in Brazil sought to gauge women’s understanding of Zika’s effect on pregnancy. They found that while most women knew the potential for birth defects, overall knowledge of sexual transmission of Zika was low. Only one out of ten of the women were using condoms to avoid transmission of Zika during pregnancy. The study also revealed a lack of reproductive health counseling as most of the women were not recommended to use contraception to delay pregnancies. (Borges et al. 7-8). This study reveals a big need for improved reproductive services and the huge potential it has for reducing the number of Zika affected pregnancies and cases due to sexual transmission.

Finally, a public awareness campaign is important to disseminate information to individuals in high risk areas on the risks of Zika and how to protect themselves. Campaigns can help reduce the number of cases by making people aware of the ways they can protect themselves from Zika and of the resources available to them if they are infected. For a public awareness campaign to be successful, it must target both men and women and additional focus must be put on reaching vulnerable populations. Public awareness campaigns can also help reduce the stigma associated with Zika and microcephaly.

For these approaches to be successful, they require coordination among key stakeholders. These stakeholders include local and national policymakers, healthcare workers, nongovernmental organizations, social system workers, environmental agencies, faith-based organizations, the media, and more (“Zika Strategic Response Plan” 15). Furthermore, we must continue to strengthen surveillance and detection systems for Zika so that cases can quickly be identified and epidemiological information can be used to best direct resources. These approaches can be expensive, but in the future can reduce the substantial economic costs associated with Zika.

Zika in the United States

The United States should be an active participant in addressing Zika because it has the potential to affect millions of Americans. Diseases like Zika do not follow borders and Zika will continue to be a risk for Americans as long as it still exists. The US is a common destination of people from Latin America and the Caribbean. In 2016, individuals from Latin America comprised 26.75% of total travelers to the US, which was an increase from previous years (Erdmann). Furthermore, Latin America and the Caribbean are common destinations for American travelers. Although Zika is no longer actively spreading in the US, it is always possible that it can begin again due to travel from high risk areas. All it takes is one infected individual to travel to the US for the epidemic to spark up again. Because the symptoms of Zika are often mild and not obvious, it could be months before it is realized that another epidemic is under way. By that time, the number of infections could already be at dangerous and hard to control levels. The 2016 outbreak in Miami demonstrated how this a very real possibility.

Besides wanting to protect its citizens from infection, the US should be interested in addressing Zika for economic reasons. One study by Lee et al. examined the potential economic costs of Zika in the US under hypothetical scenarios of differing attack rates from 0.01% to 10% in six states. The total costs calculated included both direct medical costs and productivity losses. The results found that an attack rate of 1% in all six states would result in costs exceeding $1 billion. Although the study was based on hypothetical scenarios, it still points to the high costs associated with even small attack rates. Because Zika can have long-term impacts, it is difficult to approximate the full extent of the costs, meaning the numbers in this study may be an underestimation (Lee et al. 7, 12, 17). The economic costs are especially concerning in Florida, where tourism is a billion-dollar industry. Florida, especially Miami, is at a huge risk of another outbreak due to the volume of travel back and forth from Florida to Latin America and the Caribbean. Zika has the potential to derail tourism, which can affect the economy and thousands of jobs.

There are also economic benefits when the US funds global health research and development. The vaccines, drugs, and other technologies that the US helps to advance with funding result in lowered healthcare costs around the world and at home. For example, the $26 million the US put into polio research and development saved the US an estimated $180 billion in polio treatment costs. Furthermore, investments in global health spur job creation in the US and stimulate the economy. From 2007 to 2015, US investments created about 200,000 new jobs and generated $33 billion in economic output (“Return on Innovation” 3).

Conclusions

Although Zika cases have declined and the disease has slowly faded from public discussions, the problem still exists and should not be ignored. Individuals in Latin America, the Caribbean, and the US will be feeling the effects of Zika for years to come. The economic costs associated with loss of tourism and microcephaly will impact these areas for the foreseeable future. Another widespread, multi-country outbreak is still very possible. This is our window of opportunity to tackle Zika before it gets worse. The health of future generations depends on it.