The Local Health Department Response to the Zika Virus: Lessons Learned and Looking Ahead

By Umair A. Shah, MD, MPH, NACCHO President and Executive Director of Harris County Public Health in Houston, Texas

Local health departments (LHDs) have been on the front lines of responding to the Zika virus since its emergence as a public health threat in the United States (U.S.) more than two years ago. The virus, spread by Aedes aegypti (L.) and Ae. albopictus Skuse mosquitoes, carries adverse and costly health risks for pregnant women and their babies and has affected communities across the U.S. According to the Centers for Disease Control and Prevention (CDC), 2,395 pregnant women in the U.S. states and the District of Columbia have shown laboratory evidence of possible Zika virus infection to date. Additionally, NACCHO’s 2017 Forces of Change survey found that confirmed travel-related cases of Zika have been reported in nearly 90% of large LHD jurisdictions. LHDs incorporated a multi-pronged, One-Health approach to responding to the virus that included vector control, epidemiology, environmental public health, maternal and child health, community engagement, and advocacy activities.

The Local Health Department Response

The risk from Zika virus disproportionally affected certain areas of the U.S. and thus required a highly intensive local response. As is so often the case, LHD leaders and staff have been exceptional in providing education and outreach, conducting vector control and surveillance activities, and coordinating laboratory efforts and clinical testing. For example, the West Piedmont Health District in southwest Virginia developed an innovative door-to-door campaign that paired law enforcement officers with local Medical Reserve Corps volunteers to raise awareness about Zika virus prevention. The Florida Department of Health in Lee County leveraged strong partnerships, forged from past experiences related to Ebola, dengue, and chikungunya, to respond to the threats from the virus with a wide variety of local stakeholders. In an example of outstanding regional collaboration, a group of counties in New York—Westchester, Dutchess, Ulster, Rockland, Putnam, Sullivan, and Orange counties—held the Hudson Valley Regional Zika Action Plan Summit in April 2016 to coordinate their Zika efforts.

My own health department, Harris County Public Health (HCPH), was one of many LHDs in the Gulf Coast that grappled with a particularly challenging response. Harris County is the third most populous county in the U.S., spread over a geographic area larger than the state of Rhode Island, and is home to Houston, the nation’s fourth largest city. Aedes mosquitoes breed in very small pools of water, which can form in discarded tires, open containers, upturned bottle caps, and flower pots, and stay low to the ground and inside or near homes. As such, tracking Aedes in Harris County has been incredibly difficult due to the county’s sheer geographic size and diverse population.

Given the daunting challenge, innovation has been an important part of the HCPH approach to combatting Zika. Prior to the emergence of the virus, the HCPH mosquito control efforts, like most LHDs, focused on the Culex mosquito, which transmits St. Louis encephalitis and West Nile virus. Being one of the nation’s premier mosquito and vector control programs, we recognized immediately that we needed to adapt efforts to bolster our mosquito control activities to prevent Zika in our community. An example of such incredible innovation included our first-of-its-kind partnership with Microsoft Research to pilot “smart” mosquito traps using infrared technology, the traps are able to identify whether captured mosquitoes are Aedes or Culex mosquitoes based on something so intimate: yes, the individual flapping pattern of their wings! The traps thus help target specific types of mosquitoes over others, and on the back-end, collect incredibly rich data and analytics about the mosquito vectors captured. Throw in the future incorporation of drones, and you have Project Premonition with the end goal being deployment of smart-traps throughout varying terrains capable of providing departments like ours with never-before available information for real-time decision-making.

Though working with Microsoft Research is unique to our department, HCPH joins other LHDs in Texas (and beyond) in  continuing to monitoring for Zika, educating women of child-bearing age on how to stay safe, and enhancing planned responses for potential local transmission of Zika. In Texas, I am proud to report the Texas Association of City & County Health Officials (TACCHO) has provided particular leadership in this area in coordination with state and federal partners. This especially came into play during the period of local transmission in late 2016 and 2017, respectively, that was battled effectively by our South Texas LHD colleagues in Cameron and Hidalgo Counties, respectively.

Given the global nature of Zika, this has included the critical inter-connected work with colleagues across the Mexico border, in Latin America/the Caribbean, and beyond. While cases of Zika have fortunately declined since their peak, continuing to build upon newly created domestic and global partnerships remain critical in 2018 and beyond. Clearly funds provided to LHDs for situations such as Zika are best utilized with an eye toward building overall resiliency in our communities.

NACCHO’s Response to Zika: Supporting LHDs in Their Communities

NACCHO has been an important partner in helping LHDs across the country fight Zika. As the virus emerged as a major threat to public health, NACCHO created a repository of information, tools, and resources; conducted research to better understand the needs of LHDs; advocated for funding; coordinated cross-sector partners; and engaged the media. Raising the awareness of the incredibly important work that LHDs have been doing on the ground is absolutely critical in the bidirectional communication with federal partners.

In 2016, NACCHO conducted an assessment to determine the impact of the Public Health Emergency Preparedness (PHEP) funding cuts on overall LHD preparedness. The assessment found that LHDs were being called on to respond to Zika virus without adequate funding to support their efforts. NACCHO disseminated results from the assessment, creating a widely used report and infographic, issuing media statements, and even testifying before Congress.

In 2017, NACCHO surveyed LHDs to understand better mosquito control capabilities in the United States. The survey found that the overwhelming majority of vector control programs were in need of improvement. NACCHO used the survey findings to make the case for additional federal, state, and local funding for technical assistance, education, and research to support integrated mosquito management programs at LHDs.

NACCHO also maintained an ever-growing repository of resources, tools, and guidance to keep local health officials and their staff abreast of the latest developments. The information included evolving guidance from CDC and the World Health Organization, a timeline of key events, toolkits, infographics, posters and signage, and webinars. NACCHO also disseminated Zika-related resources developed by LHDs themselves for fellow LHDs.

Looking Ahead: Capacity Building

On September 29, 2017, CDC deactivated its emergency response for Zika and shifted its focus to ongoing program operations. NACCHO followed suit and has since concentrated on launching new projects that leverage lessons learned from the Zika outbreak to help members build capacity to better prepare for, respond to, and recover from future outbreaks of infectious diseases. While the threat may have diminished for now, the learning and collaboration continues. Some key examples of this include the following:

Hosting One-Day Zika Response Workshop

On March 12, NACCHO is hosting a Zika response workshop in Orlando, FL, which will provide LHDs the targeted training and technical assistance necessary for a range of Zika-related programmatic topics including mosquito control, maternal and child health, administrative preparedness, communications, and partnership-building. The workshop will feature presentations and hands-on learning activities to help LHDs bolster all aspects of Zika response.

Hosting Multi-Day Vector Control Summit

NACCHO is hosting its first 2018 Vector Control Summit on March 13–15 also in Orlando, to strengthen mosquito control capabilities in local jurisdictions. The summit will convene LHD leaders, mosquito abatement districts, public works departments, mosquito control experts, and partner organizations that were involved in Zika response efforts. The summit will provide attendees with technical assistance, education, networking, and a forum for sharing their successes, challenges, and lessons learned.

Local Health Department Maternal and Child Health Zika Capacity Assessment

NACCHO will soon be releasing a report about LHD capacity to monitor, track, and support mothers and infants potentially affected by the Zika virus. The report contains findings from an assessment of LHDs in 10 high-priority states: Alabama, Arizona, California, Florida, Georgia, Hawaii, Louisiana, Mississippi, New York, and Texas. Watch this space for more information about the report.

Concluding Remarks

Our collective experience with Zika has underscored the need for continued support that is necessary for LHDs to serve as the “boots on the ground” for Zika response activities. This includes adequate funding, evolving guidance, and technical assistance that enable agencies to meet the ever-changing public health threats of today and tomorrow. This also includes support for the role of global health in assuring strong and protected populations here in our own domestic communities – in other words, the important intersection of the global-domestic public health interface.

Zika response has reinforced another key lesson for local health officials and NACCHO staff alike: while we never know what the next danger to public health will be or where it will come from, we must remain ready. Continually strengthening the capacity and capability at the LHD level is indeed absolutely necessary to ensure we respond appropriately and robustly to the host of emerging threats that the future holds in store for all of us.





Policy statements

Repository of resources – Zika Virus: What Local Health Departments Need to Know