[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]



 
                        THE GLOBAL ZIKA EPIDEMIC

=======================================================================

                             JOINT HEARING

                               BEFORE THE

                 SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,
                        GLOBAL HUMAN RIGHTS, AND
                      INTERNATIONAL ORGANIZATIONS

                                AND THE

                            SUBCOMMITTEE ON
                         THE WESTERN HEMISPHERE

                                 OF THE

                      COMMITTEE ON FOREIGN AFFAIRS
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           FEBRUARY 10, 2016

                               __________

                           Serial No. 114-184

                               __________

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                      COMMITTEE ON FOREIGN AFFAIRS

                 EDWARD R. ROYCE, California, Chairman
                 
CHRISTOPHER H. SMITH, New Jersey     ELIOT L. ENGEL, New York
ILEANA ROS-LEHTINEN, Florida         BRAD SHERMAN, California
DANA ROHRABACHER, California         GREGORY W. MEEKS, New York
STEVE CHABOT, Ohio                   ALBIO SIRES, New Jersey
JOE WILSON, South Carolina           GERALD E. CONNOLLY, Virginia
MICHAEL T. McCAUL, Texas             THEODORE E. DEUTCH, Florida
TED POE, Texas                       BRIAN HIGGINS, New York
MATT SALMON, Arizona                 KAREN BASS, California
DARRELL E. ISSA, California          WILLIAM KEATING, Massachusetts
TOM MARINO, Pennsylvania             DAVID CICILLINE, Rhode Island
JEFF DUNCAN, South Carolina          ALAN GRAYSON, Florida
MO BROOKS, Alabama                   AMI BERA, California
PAUL COOK, California                ALAN S. LOWENTHAL, California
RANDY K. WEBER SR., Texas            GRACE MENG, New York
SCOTT PERRY, Pennsylvania            LOIS FRANKEL, Florida
RON DeSANTIS, Florida                TULSI GABBARD, Hawaii
MARK MEADOWS, North Carolina         JOAQUIN CASTRO, Texas
TED S. YOHO, Florida                 ROBIN L. KELLY, Illinois
CURT CLAWSON, Florida                BRENDAN F. BOYLE, Pennsylvania
SCOTT DesJARLAIS, Tennessee
REID J. RIBBLE, Wisconsin
DAVID A. TROTT, Michigan
LEE M. ZELDIN, New York
DANIEL DONOVAN, New York

     Amy Porter, Chief of Staff      Thomas Sheehy, Staff Director

               Jason Steinbaum, Democratic Staff Director
               
               
    Subcommittee on Africa, Global Health, Global Human Rights, and 
                      International Organizations

               CHRISTOPHER H. SMITH, New Jersey, Chairman
               
MARK MEADOWS, North Carolina         KAREN BASS, California
CURT CLAWSON, Florida                DAVID CICILLINE, Rhode Island
SCOTT DesJARLAIS, Tennessee          AMI BERA, California
DANIEL DONOVAN, New York

                                 ------                                

                 Subcommittee on the Western Hemisphere

                 JEFF DUNCAN, South Carolina, Chairman
                 
CHRISTOPHER H. SMITH, New Jersey     ALBIO SIRES, New Jersey
ILEANA ROS-LEHTINEN, Florida         JOAQUIN CASTRO, Texas
MICHAEL T. McCAUL, Texas             ROBIN L. KELLY, Illinois
MATT SALMON, Arizona                 GREGORY W. MEEKS, New York
RON DeSANTIS, Florida                ALAN GRAYSON, Florida
TED S. YOHO, Florida                 ALAN S. LOWENTHAL, California
DANIEL DONOVAN, New York
                            
                            
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page

                               WITNESSES

Tom Frieden, M.D., Director, Centers for Disease Control and 
  Prevention, U.S. Department of Health and Human Services.......     8
Anthony S. Fauci, M.D., Director, National Institute of Allergy 
  and Infectious Diseases, National Institutes of Health, U.S. 
  Department of Health and Human Services........................    24
The Honorable Ariel Pablos-Mendez, M.D., Assistant Administrator, 
  Bureau for Global Health, U.S. Agency for International 
  Development....................................................    38

          LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

Tom Frieden, M.D.: Prepared statement............................    12
Anthony S. Fauci, M.D.: Prepared statement.......................    27
The Honorable Ariel Pablos-Mendez, M.D.: Prepared statement......    41

                                APPENDIX

Hearing notice...................................................    64
Hearing minutes..................................................    65
Questions submitted for the record by the Honorable Ami Bera, a 
  Representative in Congress from the State of California, to the 
  Honorable Ariel Pablos-Mendez, M.D.............................    66
The Honorable Christopher H. Smith, a Representative in Congress 
  from the State of New Jersey, and chairman, Subcommittee on 
  Africa, Global Health, Global Human Rights, and International 
  Organizations: Fonseca paper...................................    67



                        THE GLOBAL ZIKA EPIDEMIC

                              ----------                              


                      WEDNESDAY, FEBRUARY 10, 2016

                       House of Representatives,

                 Subcommittee on Africa, Global Health,

        Global Human Rights, and International Organizations and

                Subcommittee on the Western Hemisphere,

                     Committee on Foreign Affairs,

                            Washington, DC.

    The subcommittees met, pursuant to notice, at 1:15 p.m., in 
room 2172 Rayburn House Office Building, Hon. Christopher H. 
Smith (chairman of the Subcommittee on Africa, Global Health, 
Global Human Rights, and International Organizations) 
presiding.
    Mr. Smith. The subcommittees will come to order and 
welcome.
    In 1947, in a remote area of Uganda, scientists discovered 
a previously unknown virus among the rhesus monkey population. 
They called it the Zika virus for the forest in which it was 
found. It is endemic to Africa and to Southeast Asia. 
Scientists know that the Zika virus, like dengue fever and 
chikungunya, is spread almost exclusively through the bite of 
the Aedes species mosquito, an aggressive daytime biter. These 
mosquitos have been significantly diminished in this 
hemisphere, certainly in the United States, until the recent 
resurgence of dengue and chikungunya disease. We know a great 
deal about these disease vectors but there is much scientists 
admit they don't know about the Zika virus itself.
    Lack of knowledge and misinformation has stoked 
apprehension and fear among many. According to the World Health 
Organization, some of the reasons why we don't know more about 
this disease include a relatively small proportion, about one 
in four, some say one in five, of infected people develop 
symptoms; a virus that is only detectable for a few days in 
infected people's blood; the failure of current test to 
definitively distinguish Zika from similar viruses such as 
dengue and chikungunya.
    The World Health Organization recommends that all people in 
areas with potentially infected mosquitos, especially pregnant 
women, wear protective clothing and repellants and stay indoors 
to the extent possible with windows closed or screened. 
Pregnant women are urged to postpone travel to affected areas 
or to diligently protect against mosquito bites if travel is 
unavoidable.
    Currently, no therapeutics exist to treat the Zika virus, 
nor is there a vaccine but that gap need not be forever. One of 
our distinguished witnesses today, Dr. Anthony Fauci, Director 
of NIH's Allergy and Infectious Disease Institute will explain 
the scope of NIH research on the Zika virus, as well as vector 
control. Surely lessons learned from malaria vector control 
have applicability to Zika virus.
    Our two other distinguished witnesses include Dr. Thomas 
Frieden, who has been here many times, so many times during the 
Ebola problem, and Ariel Pablos-Mendez, the Assistant 
Administrator for Global Health at USAID, who in like manor has 
been here and has done a wonderful job on all of these issues.
    The U.S. Government has, for quite some time, promoted such 
tactics as insecticide-laced mosquito nets, window-endorsed 
screens, small pool and container drainage, and the use of 
strong but safe pesticides to eradicate mosquitos. However, our 
programs largely are tailored for developing countries. With 
the reemergence of dengue fever and chikungunya in the southern 
United States and in Hawaii, we have to step up our domestic 
efforts to control mosquitoes before warmer weather leads to an 
explosion of mosquito population during an imminent epidemic in 
the homeland.
    According to Dr. Luiz Alberto Machado, Ambassador of 
Brazil, one of the areas most affected, and he is the 
Ambassador to the United States, the Brazilian Government has 
deployed 220,000 troops and 300,000 health agents to fight the 
vector of the infection by visiting communities to educate the 
population and help eliminate all mosquito breeding grounds. 
Experts cite possible links with the Zika infection of pregnant 
mothers and disorders affecting their unborn children, while 
they, including our witnesses today, are quick to point out 
that there is no definitive proof of such a linkage.
    According to Brazil's Ambassador, and I quote him in part,

        Microcephaly in newborn babies can also be caused by a 
        number of other diseases. Health experts are dealing 
        with something new: the link between Zika and 
        microcephaly is unprecedented in the scientific 
        literature and requires in-depth studies and analyses . 
        . . .

    As a matter of fact, an AP story that just ran on February 
6th points out that the President of Colombia has said that in 
all of their cases, there is not one case of microcephaly.
    In fact, in announcing the administration's proposal for a 
supplemental sum of $1.8 billion to fund efforts to combat the 
Zika virus, the White House statement says that there ``may'' 
be a connection between the Zika virus and disorders 
experienced by newborns in affected countries.
    Dr. Marcos Espinal, Director of Communicable Diseases and 
Health Analysis at PAHO, the Pan American Health Organization, 
said there is a broad spectrum of impacts for microcephaly from 
mild to severe.
    A fact sheet on microcephaly in Boston Hospital's 
Children's Hospital notes that some children with microcephaly 
have normal intelligence and experience no particular 
difficulty with schoolwork, physical activity, relationships, 
or any other aspect of their lives. However, many children with 
the disease, especially those with more severe cases, face mild 
to significant learning disabilities, impaired motor functions, 
difficulty with movement and balance, speech delays.
    In the meantime, we must work harder to prevent maternal 
infections and devise compassionate ways to ensure that any 
child born with disabilities from this or any other infection 
is welcomed, loved, and gets the care he or she needs. USAID's 
Ariel Pablos-Mendez will testify today that we need to expand 
best practices for supporting children with microcephaly. In 
like manner, parents of children with disabilities need to be 
tangibly supported as well.
    Ana Carolina Caceres, a Brazilian journalist born with 
microcephaly, told the BBC's Ricardo Senra in a February 5th 
interview that the condition, and I quote her in pertinent 
part,

        is a box of surprises. You may suffer from serious 
        problems or you may not . . . . On the day I was born, 
        the doctor said I had no chance of survival. ``She will 
        not walk, she will not talk . . .''. But he--like many 
        others--was wrong. I grew up, went to school, went to 
        university. Today I am a journalist and I write a blog 
        . . . . People need to put their prejudices aside and 
        learn about this syndrome.

    This hearing will look into the implications of the current 
and long-term threat from the Zika virus, and we have assembled 
expert infectious health leaders from the Centers for Disease 
Control and Prevention, the National Institutes of Health, and 
the U.S. Agency for International Development to help us to 
understand where we are and where we go from here.
    I will just note, parenthetically, that for more than 4 
years, I have been urging passage of my bill the End Neglected 
Tropical Diseases Act and Dr. Pablos-Mendez has been very 
supportive and has testified at several hearings on this issue 
of neglected tropical diseases. The full Committee on Foreign 
Affairs approved it last month.
    Since 2011, our committee has accelerated our discussions 
on the need for more study and funded efforts to identify 
tropical diseases and find diagnostics, vaccines and treatments 
of such illnesses. At that time, 2011, West Nile virus was 
quietly making its way across the globe, including the United 
States, from its origins in east Africa.
    Ebola virus, first discovered in a remote area of central 
Africa in 1976, caused a global health crisis only 2 years ago.
    And finally, and I say this with some concern, for the 
second consecutive year, the administration has slashed funding 
for global health accounts in the budget proposal released this 
week, including a 19-percent cut for global program on 
tuberculosis, the world's leading infectious disease killer. 
And I know that the three distinguished witnesses today, that 
is not your prerogative but that is what was sent up to Capitol 
Hill.
    Additionally, the administration is being short-sighted 
with regard to neglected tropical diseases, cutting that 
program by nearly 15 percent. In the face of the waves of 
infectious disease epidemics in recent years, including multi-
drug resistant tuberculosis, West Nile virus, Ebola and now 
Zika, the administration's disregard for this danger is simply 
inexplicable.
    Zika has now joined the ranks of previously little-known 
diseases that have created global alarm. Before the next 
explosive health crisis appears, we must provide sufficient 
resources to the study of tropical diseases.
    I would note parenthetically, H.R. 1797 authorizes the 
creation of Centers of Excellence to study every aspect of 
these dreaded diseases. And I would note in the year 2000 and 
even most recently, just a few years ago, legislation that I 
authored on autisms created such Centers of Excellence at NIH 
and CDC and I think that has had a huge impact in combating 
that development disability. So, hopefully, we will get some 
traction on that legislation.
    I would like to now yield to the distinguished chairman, my 
good friend, Mr. Duncan.
    Mr. Duncan. I want to thank the chairman, Chairman Smith, 
for the joint hearing here and appreciate us being involved.
    The Western Hemisphere Subcommittee is wanting to engaged 
in this issue because we are seeing this virus here and there 
is a lot of concern with the allies and neighbors in the 
region. Before 30 days ago, a lot of folks in my district never 
heard the words Zika virus. So, the Zika virus, virtually 
unknown in the Western Hemisphere until the first reported case 
was on Easter Island, west of Chile in February 2014. It has 
not exploded in the region with cases in 26 counties, 
territories, and the World Health Organization projecting Zika 
will likely spread to almost every single country in the 
Americas.
    While symptoms for the majority of people who contract Zika 
are quite mild, the disturbing potential links of Zika causing 
microcephaly in unborn babies and GBS syndrome in some 
individuals has created panic around the region. Last month 
Brazil reported having over 4,000 suspected cases of 
microcephaly potentially linked to Zika as of October 2015. 
Although further investigation has confirmed microcephaly in 
just 400 of the suspected 4,000 cases, and only 17 of which 
tested positive Zika, concerns remain very real for pregnant 
women living in Zika-affected areas.
    In addition, Brazil, El Salvador, Martinique, and Suriname 
have also reported an increase in GBS cases, potentially 
connected to Zika. Just last week, Colombia confirmed the first 
three deaths of patients infected with Zika who exhibited 
symptoms similar to GBS.
    In May 2015, Pan American Health Organization issued an 
alert regarding the first confirmed Zika case in Brazil.
    Last month, the U.S. Centers for Disease Control and 
Prevention issued a Level 2 alert warning to follow enhanced 
precautions for pregnant women and women of child bearing age 
and any travel to Zika-infected places. Subsequently, last 
week, the WHO declared the spread of Zika an international 
public health emergency and President Obama has since 
responded, the request this week for Congress to provide an 
additional $1.8 billion to address the Zika crisis.
    I am deeply concerned about the impact that the Zika virus 
could have on women and future generations in Latin America and 
the Caribbean, where most of the population has little or no 
immunity, where mosquitos are simply part of everyday life, 
especially in poor communities, and where many governments' 
healthcare systems are not equipped to handle a mass influx of 
microcephaly or GBS cases as a result of the rising numbers of 
Zika cases.
    In particular, Venezuela is reporting having over 4,700 
Zika cases. With the lack of even basic healthcare options 
available due to horrible economic mismanagement, the 
Venezuela's ability to address rising numbers of Zika cases and 
provide the needed care for women in particular is severely in 
doubt and deeply worrisome, with some predicting that Venezuela 
could see the region's worst cases.
    In contrast, Brazil, the host of this year's summer 
Olympics in August, has made huge efforts to curb the spread of 
Zika by fighting it with genetically modified mosquitos, 
deploying hundreds of thousands of troops to help educate the 
population about prevention, and working with the U.S. and 
international community to research the virus and development 
treatments.
    Given the rapid spread of Zika virus in the Americas, 
several countries have tried to buy time to address the 
problems by urging women to postpone pregnancy. Colombia, 
Jamaica, Ecuador, and El Salvador have all issued these 
recommendations. However, while these governments may try to 
delay the spread of the virus through such announcements, many 
women unfortunately do not have the luxury of simply choosing 
to wait. Crime and violence plague much of the region. 
Corruption and impunity are endemic and women are often caught 
in the crosshairs, consequently facing unexpected pregnancies. 
As a result, the Zika virus has created a growing push for 
Latin American countries to liberalize their laws to allow 
greater access to contraception and abortion.
    On February 5th, the U.N. High Commissioner for Human 
Rights called on Latin American countries affected by the Zika 
virus to increase this access. Today, Latin American countries 
have some of the strongest laws on the books protecting the 
life of the unborn. Chile, the Dominican Republic, Nicaragua, 
and El Salvador ban abortion completely, while only Uruguay and 
Cuba have legalized abortion, making it widely available. Other 
countries only allow abortion in the case of rape, incest, or 
the threat of the life of the mother. This push for more 
abortion access due to the potential birth defects from 
microcephaly is heartbreaking, especially since there are 
different degrees of microcephaly in some children born with 
these special needs may go on to live very normal lives. I 
think you gave a prime example.
    Regardless, I believe every person, including the unborn 
child is made in the image of God and, therefore, has inherent 
worth. Thus, we must do everything we can to support the very 
real needs of women in Latin American and the Caribbean who are 
facing incredibly difficult situations, while also seeking to 
protect the lives of the unborn children.
    So, in conclusion, it is my hope that our witnesses today 
will provide testimony of how the U.S. and countries around the 
world, especially here in the Western Hemisphere can fight and 
protect against the spread of Zika, while simultaneously 
working together to improve healthcare that address the needs 
of women, promotes life of the unborn, and improves therapy 
options for babies born with microcephaly and individuals 
affected with GBS.
    And so with that, Mr. Chairman, I yield back.
    Mr. Smith. Chairman Duncan, thank you very much.
    I would like to now yield to Dr. Bera.
    Mr. Bera. Thank you, Mr. Chairman. Thank you for the timely 
hearing here. Obviously, this is an esteemed panel.
    As a physician who has done public health work in Nicaragua 
in areas that we are finding endemic of certainly dengue fever 
when I was down there, but now it is Zika virus, this is going 
to be a challenge. Certainly, the mosquito we are dealing with 
is not an easy one to eradicate, not an easy one to prevent. 
But the purpose of this hearing is to make sure we get 
information out and also dispell misinformation. And in 
epidemics like this, that is incredibly important because lack 
of knowledge, because the spread of misinformation certainly 
can create panic and what we want to do is reassure the public 
that we are taking this outbreak and this epidemic very 
seriously but we are doing things in a responsible way.
    I look forward to the testimony of our witnesses on how we 
are approaching this, the steps that we need to take, I applaud 
the President for his request of $1.8 billion, how we best can 
utilize those funds. But there is a lot that we don't know. I 
mean we have got to come up with more rapid diagnostic tests. 
We have certainly got to understand the extent of folks that 
are infected but also the fact that the vast majority of folks 
that do get infected probably are asymptomatic.
    We also know that there is heightened risk in women of 
child bearing age and certainly women who are currently 
pregnant. We certainly want to hear the testimony of the 
witnesses with regards to what we can be doing. But as a 
physician, myself, certainly one thing we can do in endemic 
areas is liberalizing access to contraception, making sure that 
more women of child bearing age in endemic regions have access 
to full contraception. This isn't about abortion or not 
abortion. This is about making sure that those women who are 
not planning on getting pregnant have the ability to prevent 
that pregnancy, until we get a better understanding of what we 
are dealing with. And I would make a strong push in endemic 
countries to dedicate some of those resources to access to 
those family planning services, to access to contraception, to 
access to birth control, again, incredibly important.
    For U.S. citizens that are planning on travel, obviously, 
if you are of child bearing age, we would urge you to take the 
caution. If you are pregnant, again, I would hear what those 
travel restrictions are but my sense is we would urge those 
women who are currently pregnant not to travel to endemic 
areas.
    In addition, it is my sense that given the 
interconnectedness of the globe, we have started to see some 
Zika virus cases pop up in the United States. Epidemiologically 
I would be curious, my sense is these are generally folks who 
have traveled to endemic areas who are now returning. I would 
also be curious about the epidemiology in terms of where we are 
seeing the virus. It sounds like we may potentially be seeing 
it in semen. We may be seeing it in saliva and other bodily 
fluids; so, what we can do in terms of recommendations there.
    Again, I applaud the panel here. Again, looking at this as 
a healthcare professional, I would urge that we don't panic. I 
would urge that we collect the data, the information. If folks 
are traveling to endemic areas, obviously, take the usual 
precautions to prevent mosquito bites. If you are of child 
bearing age, certainly take those precautions. I would urge 
that we do use some of the resources that the President has 
requested to make access to full contraception more available 
for women of child bearing age in these endemic regions. That 
is one simple thing that we can do to prevent congenital 
abnormalities and so forth. And again, I don't think anyone 
argues that that isn't good medicine and good prevention.
    So, again, I look forward to the testimony of the witnesses 
and, again, thank you, Mr. Chairman.
    Mr. Smith. Thank you very much.
    I would like to now yield to the ranking member of the 
Western Hemisphere Subcommittee, my good friend from New 
Jersey, Albio Sires.
    Mr. Sires. Thank you, Chairman, and thank you for holding 
these hearings. I know how much you care about world health and 
people. And this certainly is a theme, a situation that we have 
to deal with right now.
    You know the lack of clarity on the virus, and its effects, 
and its treatment make it all more important that we respond to 
this more aggressively than we have in some of the other 
diseases. I am very concerned now that we have the Olympics 
with our people going into Brazil. I think the Brazilian 
Government should be very concerned that a crisis doesn't spur 
because I don't think anybody would go to the Olympics if you 
have the situation where it gets to be panicking.
    So, I want to hear what the panel has to say and I want to 
thank the chairman again and the ranking member for holding 
this hearing. Thank you.
    Mr. Smith. Thank you very much, Mr. Sires.
    I would like to acknowledge Dina Fonseca, professor of 
entomology, ecology, and evolution at the Public Health 
Department at Rutgers in my home State of New Jersey. She is an 
expert on the mosquitos that carry Zika and other diseases and 
she has provided us some testimony that, without objection, 
will be made part of the record.
    Introducing our very distinguished panel, beginning first 
with Dr. Tom Frieden, who has been the Director of the Centers 
for Disease Control and Prevention since June 2009 and has 
dedicated his career to fighting infectious and chronic 
diseases both here in the United States and abroad.
    He led New York City's program that controlled 
tuberculosis, and reduced multi-drug resistant cases by 80 
percent, and worked in India for 5 years helping to build a 
tuberculosis control program that saved nearly 3 million lives.
    As the commissioner of New York City's Health Department, 
Dr. Frieden led programs that reduce illness and death and 
increase life expectancy substantially. He is the recipient of 
numerous awards and honors and has published more than 200 
scientific articles.
    We then go to Dr. Anthony Fauci, who is the Director of the 
National Institute of Allergy and Infectious Diseases at the 
National Institutes of Health. Since his appointment to NIAID, 
Director in 1984, Dr. Fauci has overseen an extensive research 
portfolio devoted to preventing, diagnosing, and treating, 
infectious and immune-mediated diseases. He has made numerous 
important discoveries related to HIV/AIDS, is one of the most 
cited scientists in the field.
    Dr. Fauci serves as one of the key advisors to the White 
House and the Department of Health and Human Services on global 
AIDS issues and on initiatives to bolster medical and public 
health preparedness against emerging infectious disease 
threats, such as Ebola and pandemic influenza. He is also one 
of the principle architects of the President's Emergency Plan 
for AIDS Relief.
    Then, we will hear from Dr. Ariel Pablos-Mendez, who is the 
Assistant Administrator for Global Health at USAID, a position 
he assumed in August 2011. Dr. Pablos-Mendez joined USAID's 
leadership team with a vision to shape the Bureau for Global 
Health's efforts to accomplish a measurable and sustainable 
impact in the lives of people in developing countries.
    Before joining USAID, he worked on global health strategy 
and the transformation of health systems in Africa as well as 
Asia. He also served as Director of Knowledge Management at the 
World Health Organization.
    Dr. Pablos-Mendez is a board certified internist and was a 
professor of clinical medicine and epidemiology at Columbia 
University.
    Dr. Frieden, the floor is yours.

 STATEMENT OF TOM FRIEDEN, M.D., DIRECTOR, CENTERS FOR DISEASE 
  CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                            SERVICES

    Dr. Frieden. Thank you very much, Mr. Chairman, for calling 
this hearing. And thank you, Chairman Duncan, Dr. Bera, Ranking 
Member Sires for the opportunity to discuss Zika with you.
    We look forward to a full and open discussion and I want to 
start at the outset with some basic facts. First, we are quite 
literally discovering more about Zika every single day. We are 
working around the clock to find out as much as we can, as 
quickly as we can, to inform the public and to do everything 
that we can do to reduce the risk to pregnant women.
    Zika is new and new diseases can be scary, particularly 
when they may affect the most vulnerable among us. Right now 
the most important thing for Americans to know is this. If you 
are pregnant, we recommend you not go to a place where Zika is 
spreading. And if you are pregnant and you live in an area 
where Zika is spreading, do everything you can to protect 
yourself against mosquito bites.
    The Aedes mosquito that spreads this particular virus is 
very difficult to control and I will talk about that more in a 
bit but it is a very important point, when we think about what 
we can do to respond to Zika in the short-term and in the 
longer term.
    CDC is working 24/7 to get more information. We elevated 
our level of response on Monday of this week to Level 1, after 
your activation of our Emergency Operations Center last month. 
We are committed to continuing to share information as quickly 
as possible with the public and with healthcare providers and 
policymakers, so that people can make the best possible 
decisions about health based on the most recent and accurate 
data.
    We will also continue to provide and update our guidance as 
soon as we know and learn more.
    This is the latest in a series of unpredicted and, in many 
cases, unpredictable health threats and it emphasizes how 
crucially important it is that we continue to strengthen the 
systems that will find, stop, and prevent health threats, 
wherever they emerge around the world both the help other 
countries and to protect Americans here at home.
    I want to start with what we know. As you said, Mr. 
Chairman, the virus was first identified in 1947. It was first 
identified to cause an outbreak and an outbreak that the CDC 
scientists investigated in 2007. It is believed to cause no 
symptoms in approximately 80 percent of the people infected and 
mild symptoms in virtually all of the rest. The mosquito that 
spreads it, the Aedes species. All right, there is the enemy. 
The Aedes aegypti mosquito is a very challenging, what we call, 
disease vector to control. It is an indoor biter. It bites all 
through the day, including at dawn and dusk. It hides in 
closets and under tables and places that are hard to get to. 
Its larvae or eggs, its eggs can be drought-resistant and can 
persist for some time. And it can bite four or five people in 
the course of one blood meal, meaning it can spread disease 
quite quickly. Our efforts to control it are challenging. It is 
hard to eliminate.
    I want to show a bit about what has happened in recent 
years with dengue and chikungunya. These are two viruses spread 
by the very same mosquito as Zika is. In red on this map, you 
see the approximate geographic distribution of dengue around 
the world and you see that is widely distributed in that 
equatorial band, essentially above and below, throughout the 
world. Dengue has been increasingly present in recent years.
    Now, if you look at chikungunya, chikungunya is spread by 
the same mosquito. It is a word that means bent over with pain. 
So, it can cause a severe, painful disease. And dengue, of 
course, can be very severe or fatal. And for more than 60 
years, chikungunya was present in other parts of the world but 
not in our hemisphere. But over the past few years, it has 
spread widely within our hemisphere.
    And these are the current known places where both dengue 
and chikungunya have been documented as spread. Anywhere either 
of these diseases is present, Zika may well follow in the 
coming weeks, months, and years.
    Now, on microcephaly, this is an extraordinarily unusual 
event and I want to emphasize that. In 1941, scientists 
recognized that rubella causes the rubella syndrome. And with 
rubella vaccine, we have now virtually eliminated that in the 
U.S.
    In 1962, scientists identified Cytomegalovirus, another 
virus, as a cause of severe fetal malformations. And in the 
past 50 years, we are not aware of any other viral cause of a 
significant number of birth defects. In fact, we are not aware 
of any prior mosquito-borne cause of fetal malformations, if in 
fact this is confirmed.
    Guillain-Barre syndrome, which you have heard about, or a 
weakness after infections is a recognized complication of many 
different infectious processes, both bacterial and viral. It 
can occur in one in 1,000 or one in 100,000 people who have had 
an infection and it increasingly looks like that it is 
associated with Zika virus infection as a post-infectious 
complication and it can be severe. But the big thing that is 
different here is the microcephaly.
    Next, I would like to talk about what, based on what we 
know today, is likely to happen over the coming weeks and 
months and what we are doing about it to protect Americans. 
First, we will discover more each and every day. And I will 
show you later today some new data that was just released 
within the past hour. We will learn about maternal to child 
transmission, about any possible cofactors such as other 
infections, or nutritional factors that may increase or 
decrease a woman's likelihood of having the Zika infection 
transmitted to her fetus. We will learn about the relationship 
with both microcephaly and Guillain-Barre from studies that we 
are doing today with partners in Brazil, Colombia, Puerto Rico, 
and other places.
    We will develop better diagnostics. Currently, we can 
diagnose the active Zika infection. And when someone is sick 
with Zika, we can find it in their blood. But if it is a couple 
of weeks or a couple of months later, figuring out if they have 
had Zika is very complex. And CDC scientists have worked for 
years to develop serological tests for that. We have a test but 
it is one that can have false positives for prior infection.
    We will learn more about the level of risk, whether 
symptomatic Zika is more likely to cause other adverse health 
outcomes than asymptomatic Zika. We will learn more about how 
long a man who has been infected with Zika may continue to 
harbor Zika in semen and potentially spread it to sexual 
partners. We will learn more about how to optimally stop the 
vector, the mosquito that spreads Zika virus.
    And for all of these things, we will need additional 
resources, which is why the emergency supplemental request is 
so important.
    So, one thing that will happen is we will learn more. A 
second thing that will happen is we will see more cases among 
travelers to the U.S. Some of them will be pregnant and that is 
why we have issued travel advice not to travel if you are 
pregnant and we have worked with doctors, clinicians, and 
others to provide that advice.
    Third, we will likely see significant numbers of cases in 
Puerto Rico and other U.S. territories, where there may be 
intensive spread of Zika. This is a particularly urgent area 
and I would like to show you a series of slides that show what 
happened in the chikungunya outbreak a little under 2 years 
ago.
    On May 5, 2014, the first chikungunya case was identified 
in Puerto Rico. Two weeks' later, it had begun to spread and 
each of these slides is a 2-week period. Two weeks later, 2 
weeks later, 2 weeks later, and by October, it was in almost 
all of Puerto Rico and has now affected at least a quarter of 
the adult population of Puerto Rico. So, this can spread very 
rapidly in a population.
    We will move rapidly to support pregnant women and reduce 
the risk that pregnant women will become infected, to monitor 
and reduce mosquito populations to the greatest extent 
possible. And the next thing that we may see happen is cases or 
clusters in part of the U.S. that have had dengue clusters in 
the past. That is why we need support for local mosquito 
surveillance and control measures. We may also see sporadic 
cases elsewhere in the U.S. and, of course, unfortunately, 
continued spread around the world.
    To finish what we are doing now is, in a whole of 
government way but with HHS as the lead, looking at what can be 
done to reduce the risk to pregnant women. And the CDC part of 
the supplemental request is $828 million to scale up 
prevention, both for pregnant women, for reducing the risk of 
mosquitos, to prevent transfusion, organ transplant, or other 
what we believe are rare potential forms of transmission and in 
the future, with NIH in the lead, vaccination.
    To detect through laboratory tests, CDC laboratories have 
developed the diagnostics that are being used in this country 
and we are working around the clock to get these diagnostics 
out so that more people who want to be tested can be tested. We 
will improve clinical diagnosis and reporting, mosquito 
surveillance, and including the resistance of mosquitos to 
insecticides, which is very important to know so we can target 
our actions, and to understand microcephaly more.
    Within the past hour, CDC has released information from 
Brazil on the findings among four infants, two miscarriages at 
age 10 and 11 weeks, spontaneous miscarriages, and two infants 
who tragically had microcephaly and died within the first 24 
hours of life. And working with our Brazilian colleagues, the 
CDC laboratory was able to identify the genetic material of the 
Zika virus in the brain tissue of the two infants who died with 
microcephaly. This is the strongest evidence to date that Zika 
is the cause of microcephaly but it is still not definitive. We 
will still need to understand the clinical and epidemiological 
patterns to make that link definitive.
    To do these investigations and to do the response, we will 
need additional resources. Vector control is complex and 
expensive. There are a series of measures we can take, 
particularly in the U.S. area of Puerto Rico and other parts 
that have had dengue transmission and we look forward to 
working with you to inform people about the latest information 
on Zika and what we can do to stop it.
    So, thank you very much and I look forward to answering 
your questions.
    [The prepared statement of Dr. Frieden follows:]
    
    
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    Mr. Smith. Dr. Frieden, thank you very much for your 
testimony.
    Dr. Fauci.

    STATEMENT OF ANTHONY S. FAUCI, M.D., DIRECTOR, NATIONAL 
    INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES, NATIONAL 
   INSTITUTES OF HEALTH, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                            SERVICES

    Dr. Fauci. Thank you very much, Mr. Chairman, Chairman 
Duncan, Dr. Bera. It is a pleasure to be with you this 
afternoon and to discuss with you the research conducted and 
supported by the National Institutes of Health in addressing 
the Zika virus situation that we currently find ourselves in.
    It is important to point out that we are part of a 
government-wide and HHS concentrated effort with our sister 
agencies CDC, FDA, and others within HHS to address the public 
health issue of Zika. Our role is in the area of basic and 
clinical biomedical research.
    As shown on this slide, the National Institute of Allergy 
and Infectious Diseases, the institute that I direct, has a 
dual mandate. And the mandate is to not only, in the classic 
way, support a robust basic and clinical research portfolio in 
microbiology infectious diseases, but simultaneously, to be 
able to respond almost immediately to a new and emerging 
threat, the situation we find ourselves in right now with Zika.
    As I wrote in this article just a few weeks ago in the New 
England Journal of Medicine, ``Zika Virus in the Americas: Yet 
Another Arbovirus Threat,'' and the point that I made in this 
article is that if you look just in the Americas, 
notwithstanding the rest of the world, over the last few 
decades, what we have seen was an explosion of not only dengue 
virus but new viruses that had never before been seen in the 
Western Hemisphere. Dr. Frieden mentioned a couple of those: 
West Nile virus, chikungunya virus in the Caribbean, and now 
Zika virus in the Americas. These are mosquito-borne viruses 
that have the capability of spreading very rapidly. And what we 
have been able to do, and I am going to describe a bit of that 
for you and then, obviously, leave time for questions later, of 
what the approach of the NIH and NIAID has been.
    Our major mandate is to provide the basic understanding of 
the disease, the clinical research, the resources for 
researchers throughout the country and the world, as well as 
biotech companies, with the ultimate goal of developing what we 
call our countermeasures in the form of diagnostics, 
therapeutics, and vaccines. So, let's take a very quick look at 
some of these and how they relate to the situation with Zika.
    Dr. Frieden mentioned the issue of epidemiology and natural 
history. We have our grantees and contractors who have been 
studying similar diseases like the flavivirus dengue to try and 
understand what we call the natural history. What is the 
difference between symptomatic and asymptomatic disease and 
what is the relationship direct or indirect, alone or 
synergistic between an infected pregnant woman and the 
development of congenital abnormalities like microcephaly? 
What, indeed, is the broad spectrum of the pathogenesis of 
microcephaly? All of these are questions that we are asking 
alone and together with our colleagues, including those at the 
CDC, to try and get quick answers.
    If one looks at the basic science, if you look at other 
viruses that we have been studying, HIV, influenza, or even 
Ebola, because of the effort in trying to understand the 
fundamental molecular virology. We have put an incredible 
amount of effort and learned an awful lot. We need to do the 
same thing with Zika virus, studying the viral structure, 
comparing for example the nature of the virus in outbreaks in 
the Island of Yap, together with French Polynesia, together 
with what we are seeing now. Has it evolved? If it has evolved, 
has it impacted the pathogenesis and manifestations of disease?
    In addition, we will be establishing animal models. With 
any new disease it is important to understand pathogenesis, as 
well as to screen for drugs and test for vaccines, and animal 
models are critical to these efforts.
    Dr. Frieden mentioned the issue of vector control. There 
are a number of ways to do that, the classic ways but also some 
novel ways which we are exploring but should not take the place 
of the classic ways and that is things like the genetic 
manipulation of mosquitos or infection of mosquitos with 
Wolbachia bacteria. Again, I want to emphasize that this is not 
an easy thing to do, as Dr. Frieden has emphasized. Vector 
control is a very important tool but it is not easy to 
implement.
    We mentioned diagnostics. The CDC is taking the lead on 
that, but our grantees and contractors are using some of the 
knowledge gained from our studies in chikungunya, in dengue, 
and in other viruses to get more precise state-of-the-art, 
point-of-care specific diagnosis so we can tell a woman who may 
not know whether she got infected, whether she actually had 
been infected with Zika during her pregnancy or before.
    Importantly, our role in the development of a vaccine is 
actually encouraging news. And the reason I say encouraging is 
because we have had positive experience with the development of 
vaccines for other flaviviruses. Case in point, dengue, in 
which there is already an approved vaccine in Brazil and 
Mexico, and we have started last month a Phase 3 trial of a 
dengue vaccine candidate in Brazil, in collaboration with the 
Instituto Butantan.
    In addition, for West Nile virus, another flavivirus, we 
successfully made a vaccine. Unfortunately, even though we went 
through Phase 1 clinical trials with good safety and 
immunogenicity data, we could not find a pharmaceutical company 
that wanted to partner with us because it was felt that this 
was not something that would have a good profit because of the 
target population for this vaccine. I don't believe at all that 
we will be left with this problem with Zika, since we already 
have a considerable amount of interest on the part of 
pharmaceutical companies. We are going to use the same 
technologies that we used to develop the vaccines for other 
flaviviruses. We are already manufacturing what we call the 
construct for that, which we will make to the point of GMP, 
conduct toxicity studies, and get into a Phase 1 trial I would 
think, and almost be certain, by the middle of this summer, 
which will be asking for safety and immunogenicity.
    This is the schematic diagram of the vaccine that we used 
for West Nile. It is what is called the DNA construct in which 
you insert the gene first of West Nile virus. We will 
substitute the gene of Zika virus, inject it into an individual 
which would produce now viral-like particles which we know are 
safe and we know they are immunogenic.
    And also therapeutics, although it isn't as high a priority 
as vaccines, since it is a transient infection and we have to 
do a lot of screening, we, nonetheless, are looking very 
carefully with our drug screening capability at possible 
therapeutics for the entire class of flaviviruses.
    I want to close with this last slide, which reminds us of 
something that I said in the very beginning of my presentation, 
that microbes have emerged, are emerging, and will continue to 
emerge. And I refer to it as the perpetual challenge because we 
know that we are talking about Zika today and next month or 
next year, we will be talking about something else in the same 
way as last year we spoke about Ebola. And I know I want to 
thank the Congress for the support that you have given us over 
the years to allow us to address these problems.
    Thank you very much, Mr. Chairman. I will happy to answer 
any questions.
    [The prepared statement of Dr. Fauci follows:]
    
    
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    Mr. Smith. Dr. Fauci, thank you very much for your 
testimony. Without objection, all of your full statements, 
which are very lengthy and detailed will be made a part of the 
record.
    I would like to now go to Dr. Pablos-Mendez.

STATEMENT OF THE HONORABLE ARIEL PABLOS-MENDEZ, M.D., ASSISTANT 
   ADMINISTRATOR, BUREAU FOR GLOBAL HEALTH, U.S. AGENCY FOR 
                   INTERNATIONAL DEVELOPMENT

    Dr. Pablos-Mendez. Thank you, Chairman Smith, Chairman 
Duncan, Ranking Member Sires, and Dr. Bera and all the 
distinguished members of the subcommittees for inviting me here 
today to testify on the United States Agency for International 
Development, USAID's response to the serious concerns raised by 
the spreading in the Americas of the Zika virus.
    And I want to recognize the leadership of my colleagues, 
Dr. Frieden and Dr. Fauci that have been rapidly mobilized in 
the response and the immediate investigation that we already 
are learning a lot. But as we have learned from other 
outbreaks, we cannot wait to figure it all out before we begin 
to have this discussion and a response.
    And on Monday, the President submitted a Fiscal Year 2016 
supplemental request to aggressively respond to the Zika virus 
outbreak. The supplemental request includes $335 million for 
programs to be implemented by USAID so that we can help 
countries in the region affected by Zika respond and protect 
their citizens and, in doing so, attenuate its spread to our 
homeland.
    Let me briefly describe the components of the work that we 
propose for implementation by USAID. First, we will support 
brisk communications and behavior change programs. As Dr. Bera 
recognized, getting the right information to the people, 
empowering people with the right information, and this is going 
to be a rapidly evolving field, we don't want panic to take 
place in the region as we actually take actions to help protect 
themselves from the Zika, as well as other mosquito-borne 
diseases. This includes mobilizing communities on vector 
control, providing clear information for women concerning the 
risk of the Zika virus and pregnancy, and how to protect 
themselves. Community level messaging will be combined with 
mass media and social media campaigns. We will also partner 
with the private sector and I am in discussions with companies 
in Brazil at this moment to help us do that.
    Secondly, USAID will support implementation of a package of 
integrated vector management, vector control activities in 
communities at risk of Zika. This will help reduce exposure to 
mosquitos and will help protect against other vector-borne 
diseases such as dengue, as we heard just now.
    Specific activities will include community mobilization 
campaigns to reduce or eliminate standing water sources where 
Aedes aegypti mosquitos breed, focal larviciding based on 
vector mapping to eliminate major breeding sites and window-
endorsed screening to reduce mosquito entry to homes, schools, 
hospitals, and workplaces.
    The approaches we have today to reduce Aedes aegypti 
mosquito are not optimal. They have been shown to work in a 
number of settings and we certainly are going to be working 
with our partners in developing new tools and as they do, we 
want to make sure they become available rapidly in the region. 
These efforts were built upon the foundation of experience of 
the successful President's Malaria Initiative, aware that the 
Zika virus is carried by a different mosquito. We have 
expertise in mapping, expertise in entomology, and so that can 
be brought to bear also in the response to Zika.
    Thirdly, USAID will help ensure that women in affected 
countries have access to appropriate healthcare and support. 
This will include training of healthcare workers to provide 
advice, providing support for pregnant women, including helping 
them access repellant to protect against mosquitos and ensuring 
access to voluntary family planning, as we heard from Mr. 
Duncan. These will be important to have information, to have 
services, to have community, to have methods, as well as the 
care of the affected newborns. And I know that Chairman Smith 
has always had a concern for the newborn.
    Finally, innovation. We can take steps to spur development 
of new tools and other innovations to enhance our response and 
prevent future outbreaks. And the baseline of research that NIH 
leads is significant. Our partners at NIH and CDC are 
supporting this critical research already and we need to better 
understand the virus and the relationship with birth defects, 
and developing new tools.
    As we have learned, the markets need to be incentivized, 
need to be organized and market incentives can be of 
significant importance to help us bring those tools to fruition 
and to quickly deploy them in the region.
    Market incentives can be used throughout the development 
process from catalyzing early stage development of diagnostics, 
therapeutics and vaccines, and as well to incentivize most 
costly, late-stage product development manufacturing and scale.
    In response to the Ebola epidemic, USAID used grant 
challenges to rapidly source new innovations to address key 
gaps in a response and we are planning also considering new 
grant challenges to bring new ideas to bring to private sector 
in diagnostics, vector control, personal control, and the like.
    Mr. Chairman, Zika, like MERS, SARS, avian influenza, and 
Ebola all point to a landscape where the interaction between 
humans, animals, vectors is constantly changing. In our 
civilization, for the first time, we are seeing an explosion in 
the tropical regions of the world of the forestation and 
increase in need demand as economic development takes place, 
urbanization changes, and global travel and the like. 
Ecological transformation and climate, weather patterns change 
are increasingly interconnected in our world and that means 
that mosquito-borne diseases, such as Zika, can appear in areas 
they haven't before. These rapidly changing dynamics means that 
we have to be prepared for what is seemingly unpredictable and 
when we have a response, we seem to be as outsmarted by these 
viruses.
    A recent report from the National Academy of Medicine on 
Global Health Risk Framework estimates the annualized cost of 
pandemic risk is about $60 billion a year and there are other 
estimates that are actually higher than that. So, we need to 
make sure that we are prepared because both the cost in life 
and the cost to the economy is likely to grow in coming 
decades.
    As we address the immediate needs of the Zika-affected 
population, we must underscore the need to improve national 
systems to prevent, detect and respond to these pathogens and I 
think this is the effort at the heart of the Global Health 
Security Agenda launched in early 2014.
    Beyond dealing with individual outbreaks, and we are 
seeing, as Dr. Fauci put it, a perpetual challenge, one coming 
after the other, we need to also pay attention to the landscape 
where they are coming, better understand the territory where 
they are coming. USAID, for a number of years, has supported 
work that builds capacities and expands the evidence base, that 
helps predict and mitigate the impact of novel high consequence 
pathogens. And we, every year, we are detecting hundreds of 
these new pathogens. We are screening them. We are ensuring 
that they don't jump into the human space. We find them in 
primates. We find them in birds. We find them in bats. We find 
them in rodents but it is not an infinite landscape. There is a 
logic to it and we want to make sure science is brought to bear 
to address, indeed and prepare and predict these challenges.
    We must keep this bigger picture and the long-term view if 
we are to prevail against this rapidly evolving what I call the 
microbiome of the world.
    In conclusion, Mr. Chairman, USAID is strongly committed to 
combating the Zika virus outbreak of today and is strengthening 
the capacities to ensure that future threats will be rapidly 
and effectively controlled at their source and before they pose 
a threat to the global community. We look to your partnership 
and your leadership as we continue this fight.
    I appreciate the opportunity to share the contributions 
that we are making in this battle. Thank you very much.
    [The prepared statement of Dr. Pablos-Mendez follows:]
    
    
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    Mr. Smith. Dr. Pablos-Mendez, thank you very much.
    The committees will be following the 5-minute rule for 
member questioning. I would like to begin and I will just throw 
out some questions, and then yield to my good friends and 
colleagues.
    First, on vector control capacity, in Africa it took years 
to build up that capability, especially with the malaria 
efforts. I know that being safe and effective is important so 
that we don't have, obviously, unintended consequences from 
unsafe pesticides, for example. I know, personally, we use, my 
wife and I, diatomaceous earth at home for certain bugs and 
insects. Pyrethrum is obviously another possibility. But the 
question would arise, what are you suggesting that they use? Is 
there an adequate supply in these countries and an adequate 
delivery mode?
    Secondly, on Brazil, it seems that the areas of the highest 
prevalence is in areas of extreme poverty. And I know because 
we work on stunting and other issues in this subcommittee all 
the time, as a matter of fact, the first 1,000 days of life, in 
my opinion, is one of the most transformative efforts where 
nutrition, micro-nutrients, and other kinds of assistance 
efforts increases the immunity on the part of the baby. It also 
makes the mom healthier. So, from conception to the second 
birthday, those first 1,000 days are absolutely transformative. 
Are you looking into vulnerabilities based on weak or 
compromised immune systems? And certainly children living where 
there is extreme poverty and lack of nutrition are likely to 
have that problem.
    Third, on mother-to-child transmission, is that something 
that you will be looking to develop a way like you, the 
pharmaceuticals and others did so effectively with regards to 
mother-to-child transmission with HIV/AIDS?
    And then finally, in the United States landmark civil 
rights legislation, the Americans with Disabilities Act ensures 
that persons with disabilities are fully enfranchised into 
society. Dr. Pablos-Mendez, you mentioned in your testimony, 
looking to encourage other countries to adopt best practices 
for supporting children with microcephaly, you might want to 
explain what that will look like in terms of helping those 
countries care for children with disabilities.
    Dr. Frieden. Maybe I can start with your first couple of 
questions.
    On vector control, our approach is to reduce mosquito 
populations by an integrated comprehensive approach. That means 
reducing standing water, using larvicides, and there are 
various forms of larvicides.
    We have looked at outdoor spraying and many countries use 
outdoor spraying. Because the vector bites indoors and because 
of some other characteristics, there may be limited 
effectiveness of outdoor spraying.
    And one approach that has been used in some places is 
targeted indoor residual spraying. It is a different type of 
spraying than spraying done with malaria, different areas of 
the house, but there may be efficacy there. That is a labor-
intensive and complex area.
    And underlying all four of those critical approaches is 
rigorous surveillance for where the mosquitos are and which 
insecticides they may be resistant to. And we have those 
studies underway now in Puerto Rico. We don't yet know what the 
resistance levels are.
    In terms of nutritional or other cofactors and the impact 
of poverty, that is exactly one of the things that we will be 
studying in the case control study. There is a lot that we 
don't know. If there is a causal association, we don't yet know 
which trimester of pregnancy is the highest risk and, within 
that, whether it is all pregnancies or a small proportion of 
them that is affected. And if it is fewer, what might be the 
risk or protective factors? That is a critical thing that we 
are investigating now.
    Dr. Fauci. Thank you, Mr. Chairman, let me just address the 
question of mother-to-child transmission, which is really 
important. The major difference between mother-to-child 
transmission and the advances that we have made with HIV/AIDS 
and the particular challenge of Zika infection in the mother 
and the transmission to the baby is the chronic nature of the 
viremia in HIV in which you could suppress the virus in the 
mother by treating the mother. And we know for certain, by many 
good studies, that when you bring the level of HIV viremia in 
the mother to below detectable level, you dramatically decrease 
the likelihood that the mother will transmit HIV to the baby 
because you have a lot of time because it is a chronic 
infection.
    When you are dealing with an infection like Zika, which is 
a flash infection, it comes, it lasts a few days, and then it 
is gone in the person who gets infected, the way to prevent 
mother-to-child transmission is exactly what we did with the 
rubella model. You recall that in the 1960s there were 20,000 
cases of congenital rubella syndrome annually in the United 
States. That is astounding, 20,000 cases, leading to blindness, 
deafness, heart disease, mental retardation, and other types of 
congenital abnormalities. If you look at the curve of the 
epidemiology, when we instituted the rubella vaccine, we 
essentially targeted everyone--it was specifically targeted to 
women of child-bearing age because rubella is a relatively mild 
disease very similar to Zika.
    In answer to your question about mother-to-child 
transmission, the best way to prevent that is to get an 
effective vaccine and make sure that in the target countries, 
women of child-bearing age are protected by a vaccine.
    Dr. Pablos-Mendez. Mr. Chairman, I would like to address 
two of your points, one on nutrition and the other on children 
with microcephaly and disabilities.
    We fully agree. Just yesterday we having a review of our 
nutrition portfolio and the first 1,000 days had been the way 
in which our work has been best framed to have the most impact 
but also we drew on the parallels to the current situation with 
Zika. Those first 1,000 days needs to be crucial, crucial both 
to the prevention because as you said, malnutrition will expose 
you to severe infection and then that is the complications that 
we may be seeing.
    Also, malnutrition could play a role itself in leading to 
under nutrition in utero and even associations of certain 
deficiencies with complications and deformations and the like.
    But the experience and the work that we have in nutrition 
around the first 1,000 days also bring to bear anthropometrics. 
The measurement of the heads, for example, is something we need 
to do better. We need to have surveillance and reporting system 
that allows us to do that and the experience and the community 
centers that we have working in nutrition can be mobilized in 
this regard.
    As you know, we have been very successful with child 
survival. One hundred million children's lives have been saved 
in the last 20 years. And in a way, we are looking to the end 
of preventable child and maternal death and, as we do that, we 
move from survival to well-being. And the more we do that, we 
pay attention, indeed, to many of the factors from nutrition 
education that we have to do, disabilities very important. And 
the U.S. Government leadership in that space for Americans but 
also in the U.N. there has been awakening of the importance of 
paying attention to support for children with disabilities.
    The experience we have built on HIV and more recently on 
Ebola, in terms of those who are affected, in terms of 
education on the stigma, medical care, and research, as to what 
will be the spectrum of the impact of these phenomenon we are 
working on today, and social work to support those families. 
There is a lot of needs.
    We do have, as you know a Center for Children in Adversity 
at USAID that has been working in this area. So, we look 
forward to continue to work with you. And we have all of these 
to mobilize in a region that we have in a way not been as 
present because of the success in development in this region. 
We have moved most of our resources to Africa and Asia, where 
we had the most deaths maternal child health, as well as AIDS, 
malaria, and tuberculosis.
    Mr. Smith. Thank you.
    Dr. Bera.
    Mr. Bera. Thank you, Mr. Chairman. And I will try to keep 
my remarks tight because I know we just we got votes called and 
we have got a number of members.
    I think Dr. Frieden pointed out the difficulty of vector 
control with this particular mosquito, obviously, that is one 
of our primary tools but, again, not as easy as with certain 
other types of mosquitos.
    Dr. Fauci, you touched on the importance of developing a 
vaccine and perhaps the rapidity of developing that vaccine. I 
would be curious, you were pretty optimistic that we might be 
able to develop something fairly quickly.
    Dr. Fauci. Let me explain that so that it is clear. In 
general, vaccines take anywhere from 3 to 8 years to get all 
the I's dots and the T's crossed, full FDA approval by proving 
safety and efficacy.
    When you are dealing with a situation like this, we have 
the advantage that we already have the construct that you need, 
the candidate vaccine platform. If you look at the timetable, 
you always know that in vaccinology you have to be careful that 
timetables can slip. But we feel confident that we will have 
enough construct to be able to do preclinical toxicity studies 
by this summer, which means we could start a Phase 1 trial, 
let's say in August. They usually take 3 to 4 months, which 
means we could be finished by the end of 2016.
    Now, the critical issue. If it is safe and immunogenic and 
the outbreak is still raging, then you could go into an 
accelerated Phase 2A/2B trial, which means that you could 
likely determine if it is effective within 6 to 8 months. And 
if it is, you can get an accelerated approval from the 
regulatory bodies. However, if when we get to 2017, all of the 
cases go down, which is what we faced with Ebola. We had an 
Ebola vaccine and then all of a sudden, the cases disappeared 
and it was difficult to definitively prove. If it goes down, 
then you stretch it into several years. But if I am talking to 
you in February 2017 and we still have a massive outbreak in 
South America, we likely could prove safety and efficacy within 
6 to 8 months.
    Mr. Bera. Now, are we going to run into, in terms of 
commercialization of that vaccine and wrapping up that vaccine, 
you know working with the private sector to get that vaccine 
commercialized and distributed, will that be a problem?
    Dr. Fauci. I do not think so, Dr. Bera. And the reason I do 
not think so is because we are already, unlike the case with 
other emerging infections, receiving calls from pharmaceutical 
companies, big pharmaceutical companies very interested in 
partnering with us. I don't think we are going to have that 
problem.
    Mr. Bera. Great. And again, all three of you touched on the 
importance of funding global health, the importance of funding 
global disease surveillance. You know this is just another case 
of the interconnected world. Disease is going to travel a lot 
faster and so forth. And I would just put out there the 
importance of funding and making those funds available and 
working together.
    This is, again, just, you know we had Ebola last year. We 
have got Zika virus today. We will have another infection next 
year and again, I would emphasize the importance of this 
funding.
    So, Mr. Chairman, I will go ahead and yield back.
    Mr. Smith. We have a series of votes. I am not sure what 
your availability is to stay. We could be back in about 15 or 
20 minutes. Would that be okay? I deeply appreciate it.
    We stand in brief recess.
    [Recess.]
    Mr. Smith. The subcommittees will reconvene. And as soon as 
my colleagues who come, since I have already had my turn, I 
will yield to them.
    But I did ask the question earlier and maybe if you could 
just elaborate a bit on it and that is the capacity, the actual 
volume of potential pesticides. I know Dr. Frieden, you talked 
about the utter importance of draining sitting water. And I 
know even in the Big Island in Hawaii, there is just a new 
emergency call because of dengue to go after spare tires that 
are housing water and then becoming breeding grounds for 
mosquitos. I get that. That is labor intensive but doesn't 
require chemicals, per se. What are the actual pesticides that 
are considered safe and what is the potential supply of those?
    Dr. Frieden. Thank you very much. I am glad you came back 
to that because I wasn't able to address some of the really 
critical issues there in my earlier reply.
    The U.S. capacity for mosquito control is quite variable. 
So, some parts of the U.S. do this extremely well, some parts 
not so well. And one of the critical components of the 
supplemental request is to strengthen mosquito control in the 
parts of the U.S. that have mosquitos that could spread the 
Zika virus. And here, we look at a comprehensive approach.
    So, on the one hand there are things that you can do to 
reduce larval populations and their use of what is called BTI 
or Bacillus and the sphaericus, two different bacteria that 
actually infect and kill the larval mosquitos are very 
effective and are used pretty widely in not just human health 
but agriculture and other areas. There are various other ways 
of reducing mosquito larva populations but that is one of them.
    For the adult mosquitos, there are three broad classes of 
insecticide and then within those there are many different 
types of insecticides. Not all of them are licensed for use in 
the U.S. and we are looking very carefully at what has been 
done in other countries, including Australia with targeted, 
indoor residual spraying of insecticides and seeing what would 
be safe and effective here. So, that is something that we are 
in frequent discussions with industry partners, as well as EPA 
and other entities. But there are issues of what we could do 
that is safe and effective.
    The mosquito control efforts are also more than just 
chemicals. It is about having a surveillance system. So, CDC 
has invented a type of trap which is currently in use in 
California and elsewhere that can monitor what the mosquito 
populations are. CDC laboratories have developed a simple way 
of testing for insecticide resistance so that we can get a 
better sense of which should be used because we are seeing 
reports of insecticide resistance and then looking at where the 
mosquitos are and what insecticides they are susceptible to, we 
would then proceed with recommendations for mosquito control. 
But this is all quite labor-intensive. It needs to be done in 
the same way you need a public health system to find, stop, and 
prevent problems, we need a vector control or a mosquito 
control system to track where the mosquitos are and then 
respond in real time to where the problems emerge.
    Mr. Smith. Dr. Fauci, I appreciated your comments on the 
rush to get to a safe and effective vaccine. And as you pointed 
out in your testimony and in your comments, and I heard you on 
the radio talking about this recently, it may not be through 
the normal channel but we are in an emergency with regards to a 
vaccine. How quickly could such a vaccine be available?
    Dr. Fauci. Thank you for the question. If you go to a 
continually emergent situation and all things work well, if we 
finish the Phase 1 trial, as I predict we will by the end of 
2016, and we still have literally thousands of cases into 2017, 
you could then go into an accelerated Phase 2A/2B clinical 
trial. If you do the math and the statistics, depending on the 
number of cases and how effective the vaccine is, in anywhere 
from 6 to 8 months, you may be able to show that it is, in 
fact, effective and safe.
    At that point, even though it would take maybe a few years 
to get the final stamp of approval, there are mechanisms of 
accelerated approval and accelerated access that you could 
potentially implement, if in fact you have a good safety 
profile and you have shown efficacy.
    So, you could conceivably have it by the end of 2017, which 
is really rocket speed for a vaccine.
    Mr. Smith. Can I just ask anyone who would like to respond 
to this, there are about 25,000 children and adults with 
microcephaly today in the United States. Obviously, there are 
support groups. There is a great deal of knowledge that has 
been gleaned from their experiences. And as I said earlier, the 
spectrum, it is not unlike, maybe it is not a good comparison 
but it reminds me of the autism spectrum, the fact that there 
are people who are severely autistic and some who are higher 
functioning. And I am wondering if some of those lessons and 
from those groups like Boston Children's Hospital which has 
done wonderful work in that area, are you looking to tap that 
so that we share best practices with these countries which may 
not have that experience?
    Dr. Frieden. Yes, thanks for the question. As you know, Mr. 
Chairman, from your past work, the Centers for Disease Control 
and Prevention includes the National Center for Birth Defects 
and Developmental Disabilities. And in our emergency response, 
they are fully integrated, including clinical geneticists, who 
are traveling to Brazil and Colombia to assist with assessment 
and plans.
    We need to learn more about what the spectrum is in this 
case. As noted, we may well see a broad spectrum of some more 
severe, some less severe, and this is something that we want to 
provide all of the expert assistance we can to support women, 
families and communities that are dealing with this very 
challenging situation.
    Mr. Smith. Yes, Dr. Pablos.
    Dr. Pablos-Mendez. Just to add, one of our partners in the 
Saving Lives at Birth Initiative is the American Pediatric 
Association. So, we are working already with them and they can 
help us bridge domestic lessons to the progress we are 
deploying internationally.
    Mr. Smith. I appreciate that very much.
    I would like to now yield to the distinguished chairman of 
the Western Hemisphere Subcommittee.
    Mr. Duncan. Thank you, Mr. Chairman.
    There are going to be a lot of folks traveling to Brazil 
this summer. What steps are being taken in Brazil that you can 
tell us about? We have even heard calls for canceling the 
Olympics because people are concerned.
    So, what are the Brazilians doing? What are you doing to 
help? And what do we need to know?
    Dr. Frieden. So, Brazil has taken this very seriously. They 
consider it, I think, an absolute top national priority and, as 
the other chairman mentioned in his opening remarks, they have 
deployed hundreds of thousands of people in the response. They 
are working to reduce mosquito populations. They are trying new 
forms of mosquito control. They point out that the season of 
the Olympics is a cooler season, so generally has less mosquito 
activities, though not none.
    But I think from our standpoint at CDC, our role is to give 
travel advice to people, regardless of why they are traveling. 
So, whether someone is traveling for the Olympics or any other 
reason, our advice would essentially be the same. And from the 
very first days when we had strong evidence suggesting a link 
between the presence of Zika virus and microcephaly, we have 
advised that pregnant women strongly consider not going to a 
place that has Zika spreading.
    So, that is our advice from CDC. And that for women who 
live in such areas, or people who go there, to take really good 
steps to prevent mosquito bites. And there are things you can 
do, applying DEET multiple times a day, mosquito repellant, 
wearing long-sleeve shirts and long pants, using clothing that 
has permethrin treatment, so it repels mosquitos, and, to the 
extent possible, staying indoors within air conditioning, or at 
least screened and enclosed spaces.
    And I think as we learn more in the coming weeks and 
months, more will be understood about what can be done to keep 
any risk that might be there to the absolute minimum.
    Mr. Duncan. I think it will definitely smell like DEET down 
there, sure enough.
    I was in Pucallpa, Peru and there is a mosquito and dengue 
research project going on and tracking individuals that may 
have been contracted and where they have traveled to and who 
else may have been exposed or mosquitos in that area.
    A lot of folks in my district are concerned, Mr. Chairman, 
about unaccompanied children coming north from Latin America. 
It has been an issue. Now, it is been exacerbated with Zika. 
And do we need to know anything? I mean how prevalent for a 
child, a minor to carry a disease? I know you said it has got a 
very short period where its symptoms are prevalent but are we 
researching how long an adolescent would carry the disease and 
whether say they come north of the border and are bitten? Do 
you see where I am going with that?
    Dr. Frieden. Yes.
    Mr. Duncan. So, what do we need to know about that?
    Dr. Frieden. So, we have studied this in a variety of prior 
outbreaks, as have others. The virus stays in the blood for 
about a week after people begin to get sick. We don't see long-
term persistence. So, unlike for example HIV or hepatitis which 
can stay in your blood really for life, this is a short-lived 
virus that doesn't persist in the blood beyond a week. And if 
you think about the numbers, they are really quite striking. 
There is a lot of travel from Americans going to Central and 
South America and the Caribbean on the order of 40 million 
visits per year.
    So, lots of travel. And if you think about the different 
types of travel, that is a very large number compared to 
different types of risk.
    The one area I would, just to give full information, what 
we don't yet know is how long the virus can persist in semen. 
And we are doing studies on that but that is the one area where 
we might see the potential for transmission through sexual 
contact for more than a week. And we won't know until we do the 
studies. That is why we have recommended that for men who have 
sexual contact with women who are pregnant, that to avoid the 
transmission of Zika----
    Mr. Duncan. Right, you had mentioned that earlier. I get 
that.
    So, when Ebola outbreak was happening, we were doing 
airport screening of folks that had traveled to the African 
continent, especially those three main countries. Latin America 
travel is much broader than that. Is there any proposal, any 
talk about doing airport screening for potential symptoms that 
you know of?
    Dr. Frieden. Yes, as you point out, the situation is very 
different. We have roughly 20,000 visitors versus 40 million. 
We have a disease which is spread from person-to-person in the 
case of Ebola, whereas it is not with other than the rare 
sexual contact.
    Mr. Duncan. The sexual activity, right.
    Dr. Frieden. Right. So, I think the situation is really 
very different in terms of Zika and our goal really is to 
protect pregnant women. That is the key priority now.
    Mr. Duncan. Right. So, we have an El Nino going on. It is 
very wet across the South. The amount of water I have seen in 
Arkansas, Louisiana, Texas, South Carolina, Alabama, 
Mississippi, and North Carolina means that there is going to be 
a lot of standing water in the South this year. That means that 
mosquitos are going to be very, very prevalent, whether they 
are in the no-see-um variety or whether they are the tiger 
variety that you mentioned earlier.
    So, what are you proposing to help the States address maybe 
a mosquito outbreak?
    Dr. Frieden. This is exactly what is one of the core 
components of the emergency supplemental request. We will be 
issuing grants to States at risk and Southern States, as well 
as U.S. territories to better control mosquito populations.
    Mr. Duncan. Right. Historically, that has been a winning 
strategy against malaria and other with mosquito-borne viruses.
    Well, listen, as someone who chairs the Western Hemisphere 
Subcommittee, who is going to be continually focused on this, 
who may see congressional travel in that area, individual 
congressmen are going to be concerned, wanting to know what 
level of information we have and how can we waylay their fears 
and the general public that continually travel down in that 
area.
    So, this has been very helpful, Mr. Chairman, and with 
that, I will yield back.
    Mr. Smith. Chairman Duncan, thank you very much for your 
questions and for this collaboration of the two subcommittees.
    I would like to now yield to Mr. Donovan, the gentleman 
from Staten Island.
    Mr. Donovan. Thank you, Mr. Chairman, and thank you 
panelists for sharing your expertise with us and welcome, my 
friend, Tom Frieden. It has been a long time. I look forward to 
visiting you in Atlanta. And thank you for all the work you did 
for the people of New York City when you were Health 
Commissioner there. I think we were fighting West Nile at that 
time. It was in its infancy stage in New York when you were the 
Health Commissioner.
    I know that you need more resources. Until we figure that 
out, is there an ability for you to redirect some resources 
that you have to address this?
    Dr. Frieden. We will do everything within our power to 
address the Zika challenge. But the supplemental calls for $828 
million for CDC in three broad areas, emergency response in 
Puerto Rico, which has a significant risk of seeing widespread 
transmission Zika, support for the continental U.S. for States 
at risk, including mosquito control diagnostics and a series of 
other measures, and then international support. And while we 
can get started with that, we can't do it at scale to the level 
that we would need and we have already had to curtail some 
other activities, such as our activities that deal with Lyme 
disease.
    Mr. Donovan. I ask that because one of the proudest moments 
I have had in the short 9 months I have been here is when we 
passed the 21st Century Cures Act to fund CDC and NIH to come 
up with remedies and vaccines for some of the diseases that are 
known in the world.
    I also realize that it takes a while, even after you have 
done your work, for the FDA to approve a lot of these things. 
Is there any mechanism in place, Tom, that we could help you 
speed that up, whether it is through legislation or something 
of that nature?
    Dr. Frieden. We have been working very closely with the FDA 
and in both Ebola and Zika, they have been able to rapidly 
allow us to use effective test technologies within a day or two 
of our asking. So, that has worked well.
    Dr. Fauci can comment further.
    Dr. Fauci. Yes, we really want to tip our hat to the FDA 
and how they have helped us with with Ebola. When we really 
needed to get the vaccine trial out quickly and go from a 
preclinical to a Phase 1, without cutting corners on safety, 
they greatly expedited their review to allow us to get the 
Phase 1 trial done here in the United States and in Europe and 
in Africa and then we went into a Phase 2 trial.
    We are working very closely with them right from the 
beginning. One of the most productive interactions that you 
have is that you involve the FDA right from the very beginning 
of a project. You don't do it and then go to the FDA and see 
how you can get something approved. They work with us right 
from the beginning, and that is exactly what they are going to 
be doing as we start developing things like vaccines for Zika. 
So, we are very optimistic about that relationship.
    Mr. Donovan. That is very comforting.
    The last comment I have, it isn't really a question but a 
comment, Dr. Fauci, during your testimony, I was dismayed when 
you told me that you worked so hard and your colleagues worked 
so hard to find a vaccine, I think it was for West Nile, and 
that no pharmaceutical company wanted to produce it because 
there wasn't a profit. All your doctors take a Hippocratic Oath 
to serve people. I am just dismayed but thank you for sharing 
that with us.
    Dr. Fauci. You are welcome. That is frustrating for us 
because we think in terms of what is good for the public health 
and the global health. And sometimes when you get involved in 
things that are profit developing, that comes in and gets in 
the way of that.
    Having said that, I feel confident that from the 
indications we are currently getting from pharmaceutical 
companies, that we won't have this problem with Zika.
    Mr. Donovan. So, we should be blessed that there is a 
profit in the Zika virus.
    Dr. Fauci. Well, unfortunately, that is a perverse way of 
doing it but you are quite correct.
    Mr. Donovan. Thank you. Thank you all.
    Dr. Pablos-Mendez. If I may add, this region may have more 
resources but we are also exploring financial mechanisms that 
we had used in the past for vaccines, where market failure 
prevent the final development by the companies. And we have an 
experience within advanced market commitment that has been done 
through the Global Alliance for Vaccines and Immunizations, 
which allowed the introduction of scale of the pneumococcal 
vaccines for children.
    Mr. Smith. The chair recognizes the gentleman from Florida, 
Mr. Clawson.
    Mr. Clawson. Thank you for coming again, guys and I am 
going to ask for some quick answers because I have got several 
questions and I think people are ready to go. Okay?
    First of all, it is the same mosquito that carries dengue, 
chikungunya, and Zika, much of the time. Is that correct?
    Dr. Frieden. That is correct.
    Mr. Clawson. And so is anybody thinking about a genetic 
therapy fix here? I don't want Frankenstein mosquitos but it 
seems to me that you get the Trojan horse and the soldiers 
inside the Trojan horse are going to die with it.
    And so as I thought about my own legislation for this 
obvious problem and being from southern Florida, it seemed to 
me that genetic fix ought to be something that is thought about 
and if you all tell me it is practical, then with my team, I am 
going to keep pursuing what we could do legislatively to 
motivate that.
    Are you all in agreement with me on that?
    Dr. Frieden. It is a promising technology. The biggest 
challenge is scalability and community acceptance.
    Mr. Clawson. Agreed but companies work all over the world 
and that acceptance factor might be different as we get closer 
to the equator. You would agree with that, too, right?
    Dr. Frieden. I don't have----
    Mr. Clawson. In terms of because you have got a bigger 
outbreak, you have got a bigger problem.
    Okay, thank you for that. We have a vaccination for dengue 
in Brazil. Right?
    Dr. Fauci. Correct.
    Mr. Clawson. I know they were working on one in southeast 
Asia for a long time. I don't remember where it got. Do they go 
quicker on this sort of thing to get vaccines in Brazil? Would 
Americans that are worried about dengue fever, should they go 
to Brazil for vaccination or are you all hesitant about the 
safety of this? It just seems like the obvious question.
    Dr. Fauci. No, actually, that is a good question. There is 
an approved vaccine in Mexico and Brazil--a dengue vaccine that 
is about 60-plus percent effective.
    Mr. Clawson. There are four different types of dengue to 
my----
    Dr. Fauci. You are correct.
    Mr. Clawson. And if you get a vaccine for dengue fever in 
Mexico, would it work in India? That is a different strain and 
sometimes a different mosquito.
    Dr. Fauci. It is the relative proportion of the serotype 
that is dominant in a particular area. The one that didn't 
quite get off the ground in Asia didn't have a good protection 
against all four serotypes; the one that is in Brazil now 
appears to cover all four.
    Mr. Clawson. So, it works better with whatever the mosquito 
here is and maybe the one adjacent that is closer in the serum, 
as you say.
    Dr. Fauci. Right. And we actually have a Phase 3 trial that 
is ongoing that started just about 4 weeks ago in Brazil in 
collaboration with the Instituto Butantan. The NIH is actually 
running the trial with them.
    Mr. Clawson. And is anybody working in Asia now, so that if 
somebody gets off a plane during the rainy season, in the 
monsoon in India, they don't bring a different strain to Mexico 
or Brazil?
    Dr. Fauci. Well, I don't think that it is a question of a 
different strain because you have four dengue serotypes that 
are essentially universally seen all over. So, even in India, 
there will be all four strains. Rather than one strain or the 
other, it is the one that is dominant.
    Mr. Clawson. Got it.
    Dr. Fauci. For example, serotype 2 is one of the most 
problematic ones.
    Mr. Clawson. Got it. Thank you.
    Okay, look, for me that is a big deal. I have had breakbone 
fever and I don't want number two and then have hemorrhagic 
complication here, guys.
    Dr. Fauci. Yes.
    Mr. Clawson. And so, as I think through that from my own 
experience, I say okay, in a world of international travel, the 
second time is going to be worse. I am in the 50 and older 
crowd, right, which makes my liver even more susceptible to 
swelling. So, we also have to think about that global nature of 
this. Am I right about that or am I missing the boat here?
    Dr. Fauci. You are correct.
    Mr. Clawson. Okay. My idea, our idea legislatively was we 
could always use government money here. It seems to me that as 
long as, to Mr. Donovan's point, as long as a drug companies 
see a profit motive, and I am always worried about that in Zika 
because I have got one of the few districts that might be 
actually impacted here, it is not going to get impacted in New 
Hampshire but it could be impacted in my district, Naples. 
Nonetheless, I mean if we gave somebody tax credits for their 
research and development in order to expedite research into 
battling this virus or coming up with a vaccine, do you see any 
downside on that, trying to accelerate the private sector to 
jump in the game here? Because it feels to me like they sat out 
dengue fever. It feels like they are sitting out chikungunya. 
And we don't want them to sit out Zika. Am I right about all of 
that?
    Dr. Fauci. Incentives to the pharmaceutical companies are 
often helpful in getting themselves engaged in this work. We 
have another way to incentivize them. What we do at NIH is de-
risk their investment. We do a lot of the work that they would 
otherwise pay for themselves so that their investment risk is 
less. Some companies take the vaccine from the concept to the 
product. They don't need anybody. They don't need the NIH. They 
don't need anybody. But when something is a public health 
imperative, and they are not interested, if we push the 
envelope to the point where we can say we have a product that 
we know is good, it is safe, and it is immunogenic, they are 
much more enthusiastic about getting involved because we have 
already made a major investment.
    In addition to what you said, which I agree with, that is a 
good way to incentivize them.
    Mr. Clawson. Can I have one more question, Mr. Chairman? 
One more question.
    So, we always think about these diseases as if they were 
malaria, which means outdoor nighttime. These are indoor 
daytime mosquitos. And so spraying, whenever I see the spray 
trucks I say well that is a wasted bullet. On the other hand, 
in our country and in my district, we don't have as much water 
sitting around, fresh water sitting around like you find in the 
Caribbean or in Brazil. If we do a good job on making sure we 
don't have a lot of pooling water around, is that enough? Are 
we going to be okay until there is a vaccination?
    Dr. Frieden. It is really going to depend on the local 
environment.
    Mr. Clawson. How about southwest Florida?
    Dr. Frieden. Well, this is one of the reasons we need the 
supplemental, to give resources so that we can look at mosquito 
populations, track them, analyze them, and then sometimes 
larviciding can have a very major impact on reducing mosquito 
populations.
    Your point is quite correct that the outdoor spraying may 
have limited impact, if any, on this mosquito population but we 
are looking at different ways of doing mosquito control. And in 
some circumstances, what they have done in Australia, for 
example, is used targeted indoor residual spraying for this 
particular mosquito with, as far as we have seen, some pretty 
effective results. But all of that is quite complex to do.
    Mr. Clawson. And let me see, just taking off on that point 
so that I understand it correctly. Because again, we want to 
get in the game here, legislatively. So, I am not asking to 
just take your time here.
    Like a lot of things, it always impacts the poor; life is 
never fair. And so in my house, I have air conditioning. If I 
see a mosquito inside, I say to myself it is not chikungunya, 
it is not Zika. So, if I get bit, I don't have to worry about 
it but someone else who may not be able to afford that is more 
at risk.
    Am I right about that? Do I understand the information 
correctly?
    Dr. Frieden. You are exactly right.
    Mr. Clawson. But that should drive some of our policy here 
as well. Pooling water at my house is not as much of a problem 
as it is going to be at someone less fortunate. Am I right 
about that, economically speaking?
    Dr. Frieden. If we look at a study done by CDC doctors and 
scientists of a dengue outbreak in Brownsville-Matamoros in 
South Texas a few years back, the rate of infection was eight 
times higher in Matamoros than it was in Brownsville.
    Mr. Clawson. Really?
    Dr. Frieden. And the two driving forces for that were air 
conditioning----
    Mr. Clawson. Really?
    Dr. Frieden [continuing]. Reduced people's risk 15-fold and 
smaller house plots, which increased crowding and increased 
risk 7-fold.
    Mr. Clawson. Right. And then even if they have air 
conditioning, they often don't have it in the bathroom, where 
the water is or in the kitchen where the water is. Am I right 
about that, too? So, it complicates it.
    Dr. Pablos-Mendez, is there anything on my line of 
questioning that you have heard me say? [Speaking foreign 
language.]
    Dr. Pablos-Mendez. [Speaking foreign language.]
    You are so knowledgeable and we discussed this last time 
when we were talking about dengue. You were almost prescient 
that clearly this scenario deserves attention.
    I just want to report that under the President's Malaria 
Initiative, we work with the Gates Foundation and many other 
partners on an Innovative Vector Control Consortium. We are 
interacting with industry. We are looking at new insecticides, 
new tools.
    That effort was focusing on Africa, malaria but that 
capability can be deployed to address this need in the region.
    Mr. Clawson. Can I interrupt just one? You are making a 
great point. I got bit at 9 o'clock in the morning in an auto 
parts plant that you are never going to air condition, right? 
So, the work environment is an area that we have got to keep in 
mind. I think that is a great point.
    Dr. Pablos-Mendez. And you are correct also, that is 
usually the poor. It is northeast section of Brazil, a poor 
area, more tropical area. So yes, there are local conditions 
that make it more likely that you will get the disease.
    The other point I would like to just mention is of course 
we do have for a while now the Orphan Drug Act that provides so 
many incentives for industry to develop diseases where 
otherwise market failure would prevent them.
    So, we have some tools and we have different markets, 
different diseases, as Dr. Fauci has alluded. We are looking at 
how we are going to work in that space so that industry is 
engaged not only in finally developing these products but in 
scaling them up and so that they can reach the poor, in 
particular.
    Mr. Clawson. You all keep talking. You all are great. And 
we need to spend some money on this. It is real-life impact on 
a lot of people, so thanks for what you are doing.
    And thanks for being so patient with me here asking all 
these questions.
    Mr. Smith. Thank you very much, Mr. Clawson. Just two final 
quick questions.
    First, I remember my first trip to El Salvador in the early 
1980s being struck by how many people--I remember being in 
Ambassador Corr's home, President Duarte was actually there, 
and there wasn't a screen in the place that I can recall. And 
for many trips to Central and South America, very often, people 
do not have screens. And even our Foreign Service Officers, 
obviously, in their homes, they are at risk, it would seem to 
me, if there are no screens.
    Is that something that is being looked at to promote 
screening as one of the best practices?
    Secondly, there are press reports that some NGOs are 
planning to exploit child disability and the potential link of 
microcephaly with Zika to promote abortion. And I am wondering 
and I am hoping, and maybe you can verify, that none of the 
$1.8 billion and the President's strategy does not have that 
agenda.
    Dr. Frieden. Thank you very much. Yes, we do believe 
screens may play a role. There are also permethrin treated 
screens that may be even more effective and this is something 
that we are very actively looking at now.
    I can assure you that the emergency supplemental request 
does not contain any proposal to change in any way current 
policy regarding abortion.
    Mr. Smith. Yes, Doctor?
    Dr. Pablos-Mendez. Well thank you very much. Indeed, USAID 
fully advised by the U.S. law, which includes a Helms amendment 
that precludes us from using any foreign assistance resources 
to pay for the performance of abortion as a method of family 
planning or to motivate, of course, any person to practice 
abortions. We don't do abortions.
    Mr. Smith. And of course the Siljander amendment makes 
clear that even the promotion is not----
    Dr. Pablos-Mendez. Correct, even the promotion.
    The only thing I will say is that because we are so careful 
with this, we monitor this very carefully everywhere we do 
work. Part of the request includes some--request because we 
will need to have staff deployed to ensure that our partners 
and the work that is deployed does not go into areas the law 
does not let us go.
    Mr. Smith. I appreciate that.
    You have been tremendous in providing information to both 
subcommittees, insights and I thank you for your service, which 
is extraordinary, and for allowing us to benefit from that 
expertise and that knowledge.
    The hearing is adjourned.
    [Whereupon, at 3:22 p.m., the subcommittee was adjourned.]

                                     

                                     

                            A P P E N D I X

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                 Material Submitted for the Record
         
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   Material submitted for the record by the Honorable Christopher H. 
 Smith, a Representative in Congress from the State of New Jersey, and 
 chairman, Subcommittee on Africa, Global Health, Global Human Rights, 
                    and International Organizations
                    
                    
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