    [Senate Hearing 114-743]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 114-743

                      ZIKA IN THE WESTERN HEMISPHERE:
                               RISKS AND RESPONSE

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

                                    HEARING

                                   BEFORE THE

                            SUBCOMMITTEE ON WESTERN

                        HEMISPHERE, TRANSNATIONAL CRIME,

                      DEMOCRACY, CIVILIAN SECURITY, HUMAN

                       RIGHTS, AND GLOBAL WOMEN'S ISSUES

                         COMMITTEE ON FOREIGN RELATIONS
                              UNITED STATES SENATE

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                JULY 13, 2016

                                   __________

           Printed for the use of the Committee on Foreign Relations

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                    COMMITTEE ON FOREIGN RELATIONS

                    BOB CORKER, Tennessee, Chairman

    JAMES E. RISCH, Idaho                BENJAMIN L. CARDIN, Maryland
    MARCO RUBIO, Florida                 BARBARA BOXER, California
    RON JOHNSON, Wisconsin               ROBERT MENENDEZ, New Jersey
    JEFF FLAKE, Arizona                  JEANNE SHAHEEN, New Hampshire
    CORY GARDNER, Colorado               CHRISTOPHER A. COONS, Delaware
    DAVID PERDUE, Georgia                TOM UDALL, New Mexico
    JOHNNY ISAKSON, Georgia              CHRISTOPHER MURPHY, Connecticut
    RAND PAUL, Kentucky                  TIM KAINE, Virginia
    JOHN BARRASSO, Wyoming               EDWARD J. MARKEY, Massachusetts

                      Todd Womack, Staff Director
                Jessica Lewis, Democratic Staff Director
                        John Dutton, Chief Clerk

               SUBCOMMITTEE ON WESTERN HEMISPHERE, TRANSNATIONAL
                      CRIME, CIVILIAN SECURITY, DEMOCRACY,
                    HUMAN RIGHTS, AND GLOBAL WOMEN'S ISSUES

                     MARCO RUBIO, Florida, Chairman

    JEFF FLAKE, Arizona                  BARBARA BOXER, California
    CORY GARDNER, Colorado               TOM UDALL, New Mexico
    DAVID PERDUE, Georgia                TIM KAINE, Virginia
    JOHNNY ISAKSON, Georgia              EDWARD J. MARKEY, Massachusetts

                                  (ii)

                                C O N T E N T S

                                  ----------
                                                                       Page

    Rubio, Hon. Marco, U.S. Senator From Florida.....................     1

    Boxer, Hon. Barbara, U.S. Senator From California................     4

    Garber, Hon. Judith G., Acting Assistant Secretary, Bureau of
      Oceans and International Environmental and Scientific Affairs,
      U.S. Department of State, Washington, DC.......................     6
        Prepared statement...........................................     7

    Frieden, Dr. Tom, Director, Centers For Disease Control And
      Prevention, Atlanta, Georgia...................................     9
        Prepared statement...........................................    11

    Koek, Irene, Acting Deputy Assistant Administrator, U.S. Agency
      for International Development, Washington, DC..................    15
        Prepared statement...........................................    16

                  Additional Material Submitted for the Record

    Zika Virus Explained, Emerging Pathogens Institute, University of
      Florida, February 19, 2016.....................................    42

    Statement Submitted by the Center for Vaccines and Immunology at
      the University of Georgia......................................    79

                                 (iii)

                        ZIKA IN THE WESTERN HEMISPHERE:
                               RISKS AND RESPONSE

                                  ----------

                            WEDNESDAY, July 13, 2016

                                   U.S. Senate,
     Subcommittee on Western Hemisphere, Transnational
    Crime, Civilian Security, Democracy, Human Rights,
                             and Global Women's Issues,
                                Committee on Foreign Relations,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 2:54 p.m., in
    Room SD-419, Dirksen Senate Office Building, Hon. Marco Rubio,
    chairman of the subcommittee, presiding.
        Present: Senators Rubio [presiding], Gardner, Isakson,
    Boxer, Kaine, Udall, and Markey.

                OPENING STATEMENT OF HON. MARCO RUBIO,
                       U.S. SENATOR FROM FLORIDA

        Senator Rubio. Thank you. Good afternoon. And today's
    hearing on the Subcommittee on Western Hemisphere,
    Transnational Crime, Civilian Security, Democracy, Human
    Rights, and Global Women's Issues will come to order. And I
    thank all of you for being here today.
        The title of this hearing is Zika in the Western
    Hemisphere: Risks and Responses. We will have three witnesses:
    Ms. Judith Garber, the Acting Assistant Secretary, Bureau of
    Oceans and International Environmental and Scientific Affairs
    at the U.S. Department of State; Dr. Tom Frieden, Director of
    the Centers for Disease Control and Prevention; and Ms. Irene
    Koek, the Acting Deputy Assistant Administrator of the U.S.
    Agency for International Development.
        We thank you all for being here today. We apologize for
    starting late. We--the Senate gods decided to schedule a vote
    right as the time we were supposed to begin. But we appreciate
    your time and your dedication.
        And I would also like to thank all of those who worked
    alongside my staff to make this hearing possible.
        Today, we face an issue that is already affecting many
    countries in our hemisphere, including our own. It is not
    partisan in nature. The growing threat of the Zika virus as a
    full-blown public-health crisis in the United States is a clear
    call to action.
        Just look that statistics. As of July, 65 countries and
    territories have reported evidence of vector-borne Zika virus
    transmission. What is even more troubling is the fact that four
    countries are classified as having possible endemic
    transmission or have reported evidence of local vector-borne
    Zika infections in 2016.
        As much as Zika remains a threat on the international
    stage, it also poses a real and timely threat to our country.
    That means, in these countries, a disease that has already
    spread rapidly and made its way into the population. We are
    seeing this, as well, is the island of Puerto Rico. And Puerto
    Ricans, as you all are well aware, are American citizens, and
    Puerto Rico is an American territory. According to the
    statistics from the World Health Organization, the United
    States is one of 11 countries with evidence of person-to-person
    transmission of the Zika virus. That means that our neighbors,
    our friends, our families are already at risk, even without
    mosquito-borne transmission, though that is likely coming, as
    well.
        As the threat of the virus continues to grow here, I will
    continue to state the importance of moving quickly in response.
    I strongly believe that inaction on Zika is simply inexcusable,
    and I am optimistic that, after reviewing the facts and hearing
    from the experts here today, it will reinforce this fact and
    the fact that something needs to happen quickly. It has taken
    far too long already. The effects of the Zika virus are
    alarming, to say the least. Pregnant women or women who have
    become pregnant have contracted the virus and are at risk of
    having babies with microcephaly.
        For those not familiar with microcephaly, it is a birth
    defect that causes severe neurological abnormalities, which can
    include small, deformed head. This has a permanent and severely
    detrimental impact on the development of the baby's
    neurological system and quality of life. Those born with
    microcephaly may experience seizures, intellectual
    disabilities, hearing and vision loss, as well as a number of
    other horrific symptoms.
        It is our responsibility to the American people to take
    action when public health is in jeopardy. Although the mainland
    of the United States may not be worried about Zika right now,
    there are already 1,133 cases, and they are found in 45 out of
    50 States. Just last week, the CDC reported that they are
    currently monitoring, in the United States, 320 cases of Zika
    in pregnant women.
        The CDC Director, who joins us here today, called Zika a
    ``silent epidemic.'' As of now, many predicted what would
    happen in the summer. The spread of the virus is now
    accelerating. The Friday before last, Federal health officials
    confirmed the largest number of new Zika infections in a single
    day in the State of Florida, with 10 new cases. That was a
    short-lived record. It was broken last Wednesday, when Florida
    confirmed 11 new Zika infections, that time in six counties,
    including Lake County, Florida, which had never had a case
    before. That record was broken again on Monday of this week,
    when 13 new infections were reported. And so, you get the idea.
    The problem is not--is only going to continue to accelerate.
        This is not the first time I have spoken on the growing
    threat of Zika. In late January of this year, as I was
    somewhere outside of Florida, I saw a headline in the New York
    Times that stopped me in my tracks. It said, ``Report of Zika-
    Linked Birth Defects Rise in Brazil.'' The article went on to
    say, ``The health authorities in Brazil said, Wednesday, that
    reported cases of microcephaly, a rare condition in which
    infants are born with abnormally small heads, had climbed to
    4,180 cases since October, a 7-percent increase from the
    previous tally last week.'' And it stopped me in my tracks, for
    a number of reasons. First was the staggering number and the
    breakneck speed with which the disease was spreading over just
    the course of a week. But it also made me pause because, for
    those of us who live in South Florida and travel through Miami
    International Airport, we know very well what happens in--we
    know very well that what happens in Brazil impacts us in the
    United States, especially in Florida.
        A couple of days after that, I reached out to the U.S.
    Customs and Border Protection to express my concerns, and asked
    what they were doing, or could do, about this, given Miami
    International Airport's standing as the Gateway to the
    Americas, with more flights and passengers going to and from
    Brazil than any other U.S. airport.
        Here on the Senate floor and back home in my State, I have
    called for action from my colleagues. I urged support for fully
    funding the President's funding request to deal with this
    virus. I have supported every single Zika proposal that has
    come before the Senate. Every single one. But nothing has
    gotten done. The problem is only getting worse.
        It is our duty to act now, while we can still get ahead of
    this disease and before it is simply too late. I believe the
    Congress has a constitutional responsibility and a moral
    obligation to confront the Zika virus. It is my hope that
    today's hearing will further call attention to the seriousness
    of this situation and what more we can do in the western
    hemisphere to help fight it. This challenge we face is
    emblematic of how interconnected we are as a country with our
    neighbors. In this global economy, public health crisis do not
    respect international borders. The negative impacts of these
    problems, from the economy to political instability, can easily
    impact us here at home.
        The links between our country, especially Florida, and
    other nations of the western hemisphere are obvious. I have
    already covered Brazil, but, for example, the first baby born
    in Florida with Zika-related microcephaly was a mother who came
    from Haiti. Last month, Time reported that 12,000 pregnant
    Colombia women have Zika. The Zika virus is already a U.S.
    public health emergency. The problem is even worse in Latin
    America. It is only growing by the day. And the links between
    our nations make this a hemispheric public health crisis,
    where, once again, American ingenuity and innovation in the
    medical sciences must lead the way if we are to help save
    lives, including countless unborn children.
        We must begin to meet the Zika virus with a sense of
    urgency that we have not seen up to now. Listen to the experts
    from around. It is time to act--it is time to enact serious
    solutions.
        I am proud to stand as an advocate for any legislation that
    would provide funding to combat Zika as soon as possible. And
    we cannot rest until we have taken action in order to ensure
    the safety and health of the American public.
        Thank you.
        With that, I recognize our ranking member, Senator Boxer.

                   STATEMENT OF HON. BARBARA BOXER,
                      U.S. SENATOR FROM CALIFORNIA

        Senator Boxer. Thank you so much, Mr. Chairman, for this
    hearing.
        Thank you, to our witnesses, our guests.
        Few issues pose as immediate a threat to the health of
    Americans as the Zika virus. The virus has caused severe birth
    defects in thousands of newborns. These birth defects include
    brain damage, blindness. They are devastating to mothers, to
    families, to communities. In some cases, we have seen the
    premature death of children.
        The Zika virus has caused a rare disorder in adults in
    which the body attacks its own nervous system, causing
    paralysis. The Zika virus is also linked with another
    autoimmune disorder that resembles multiple sclerosis, which
    causes swelling in the brain and the spinal cord. We only have
    to listen to public health experts to get a clear sense of the
    virus's danger.
        The World Health Organization has said that the Zika virus
    is, ``spreading explosively.'' in the Americas and threatens to
    overwhelm almost every country in the western hemisphere. The
    Center for Disease Control and Prevention has said the virus
    is, ``scarier than we originally thought.''
        The Zika virus is already here in the continental United
    States. Over 1,000 people have already contracted the virus
    through travel or sexual conduct. And as the disease travels
    northward from that Latin America and the Caribbean, up to 30
    States are in danger of local outbreaks from mosquitos carrying
    the virus. Thirty States. This includes California and the
    Chairman's home State of Florida. In short, we need to act now.
    It is a real threat, and it is dangerous.
        Now, here is the great news. The great news is, the Senate
    had bipartisan legislation, which is what you have when you
    have an outbreak like this. It was proposed by Senators Blunt
    and Murray. It provided the administration with less than they
    wanted, but, nonetheless, $1.1 billion. When the President
    requested $1.9 billion, the two Senators negotiated, and the
    best they could come up with was $1.1 billion. But the
    compromise would have gone a long way without having poison
    pills and ridiculous riders that are dangerous to the American
    people included in the legislation. What happened to that bill,
    that wonderful bill that my Chairman voted for, that I voted
    for, that we all voted for? It disappeared down the black hole
    of partisanship.
        The Republicans in the House had a conference, and they did
    not allow any Democrats into that conference. Not Senator
    Mikulski, a woman who we revere around here on both sides. Not
    Senator Murray, who has worked across the aisle on so many
    issues. No. They left them out. And you know what they came out
    with? A bill that actually restricts funding for birth control
    in the United States and in Puerto Rico, even though they
    know--they know that Zika can be transmitted sexually, and
    birth control should not be controversial, and it is part of
    the first line of defense. There is no room for politics in
    this.
        Listen. The report also overrides the Clean Water Act. And
    I know about this, because I am the ranking member on the
    Environment and Public Works Committee, and was Chairman of
    that committee. A landmark law that was passed by Republicans
    and Democrats. It overrides it. It allows the uncontrolled
    pesticide spraying near water supplies that we drink out of and
    our children swim in. Pesticides that could poison our people.
        Now, you may say, ``This is an emergency. Should we not be
    able to spray?'' The answer is, under the Clean Water Act, you
    can. You do not even need to get a permit. The Clean Water Act
    understands this. It is a brilliant piece of legislation. And
    it says, ``In an emergency, you do not need to get a permit. Go
    ahead and spray. Spray the amounts necessary off the approved
    list, and just notify the EPA--just notify the EPA.'' --Well,
    that was not good enough for my friends over there. They
    completely take away that whole section of the Clean Water Act.
    And that means that there is no more right to know if somebody
    goes next to your house and sprays some horrible pesticide that
    causes cancer, that is not on the approved list. You have no
    way of knowing that has happened. And the Clean Water Act is
    smart. Once the emergency is over, they sit down with the local
    agency, and they figure out a way to maintain it.
        Here we have a circumstance where the House Republicans,
    without any consultation with anybody, completely eviscerate
    the Clean Water Act. so you may not get the Zika, but your kid
    could get cancer from swimming in water that is laden with a
    pesticide that is very harmful. Where is that sensible? You
    cannot just say--I am speaking for myself--I cannot say I am
    going to vote for any bill, because what if the bill does as
    much harm as it does good? We are legislators. We have to be
    careful what we do, what we vote for.
        They took out the possibility for nonprofits to do birth
    control, which is the first line of defense against this Zika.
    They completely eviscerated the Clean Water Act, which makes it
    dangerous for our people. They even put something in there
    about the Confederate flag, which my colleague Senator Kaine
    understands, was explaining to me. He can do a better job of
    explaining it. But essentially, it overrode another bill, where
    we said you cannot fly the flag in veteran cemeteries. They did
    away with it. In the Zika bill.
        It is discouraging. And I call on all of us who voted for
    that bipartisan bill--and it is all of us here, as--far as I
    know--bring back that bill, keep out the bad stuff. Let us get
    it done. It is bad enough they cut funding for Ebola. That
    thing could rise up again. That is horrible. But these things
    are added, if you will, insults to the no--to the American
    people thinking that we are doing something good, when we are
    doing some bad things, as well.
        I just wanted to say quickly, in closing, I am so disgusted
    with the situation, as we all are, every one of us--we do not
    know how we got here. It just got here. So I am hoping we can
    do something different in the future, Mr. Chairman. And I have
    written legislation. It would create a $3 billion emergency
    public-health fund, kind of like FEMA--kind of like FEMA--where
    it would be within the Department of HHS and allow the CDC and
    HHS to use those funds to address global health threats. And it
    would allow them to go in, they would notify Congress. We could
    overrule them if we did not like it. But we would not put
    politics in the middle of this thing.
        I am, you could see, a little worked up. And I apologize.
    Maybe I am a little too worked up. But I share my friend the
    Chairman's view on this Zika thing. We are sitting on this, and
    we have to get off sitting on it and do something about it.
        Thank you.
        Senator Rubio. Thank you, Senator Boxer.
        Let--we will begin with our testimony.
        Ms. Garber--Assistant Secretary Garber.

    STATEMENT OF HON. JUDITH G. GARBER, ACTING ASSISTANT SECRETARY,
    BUREAU OF OCEANS AND INTERNATIONAL ENVIRONMENTAL AND SCIENTIFIC
           AFFAIRS, U.S. DEPARTMENT OF STATE, WASHINGTON, DC

        Ambassador Garber. Thank you, Chairman Rubio, Ranking
    Member Boxer, and distinguished members of the subcommittee. We
    really appreciate the opportunity to testify today on the State
    Department's response to the Zika virus outbreak.
        I have a longer statement that I would like to submit, with
    your permission.
        With regard to the current situation, 40 countries and
    territories in the western hemisphere are experiencing active
    mosquito-borne transmission of the Zika virus. Several
    countries and territories in Africa and Asia are also
    experiencing outbreaks for the first time.
        Since this epidemic began, science and medical experts, my
    colleague Dr. Frieden foremost amongst them, have discovered
    the truly heart-wrenching impacts that this virus can have on
    its victims, and particularly on developing fetuses.
        As you mentioned, Mr. Chairman, this is a silent outbreak.
    We do not see hospitals full of ill patients or hear ambulance
    sirens in the street. Across the hemisphere, pregnant women and
    their partners are living in fear, fear that their child may be
    born with severe developmental defects.
        In addition to the tremendous emotional and health toll of
    this epidemic on families and communities, the demographic and
    economic consequences are still emerging. The cost of lifetime
    support for children affected by Zika as well as adults
    experiencing Guillain-Barre syndrome or other neurological
    effects could significantly tax national health and education
    systems. Areas with high poverty levels and dense population
    are most vulnerable to Zika, but least able to manage the
    consequences.
        The U.S. Government is committed to helping prevent,
    detect, and respond to the Zika virus, both at home and abroad.
    Countries around the world look to the United States as a
    leader in global health security, and we are working with
    countries in the Americas and beyond to provide tailored
    support.
        Many countries in the region have governments and strong
    public health systems capable of mounting a response to Zika.
    Countries such as Brazil, Panama, and Colombia host respected
    research institutions with which we are partnering to learn
    more about the virus and develop countermeasures. Through
    regional institutions such as the Pan American Health
    Organization and the Organization of American States, the U.S.
    Government and our neighbors are leveraging our collective
    expertise to share best practices and identify innovative tools
    for vector control and disease diagnosis. In countries such as
    Haiti, El Salvador, Guatemala, Honduras, and the Dominican
    Republican, the United States is providing more direct
    assistance to effectively respond to the Zika virus threat. Our
    embassies are working closely with these governments and
    international organizations such as the World Health
    Organization to identify capacity gaps and prioritize
    assistance.
        U.S. voluntary contributions and other support to our
    regional and multilateral partners enable us to leverage U.S.
    funding and amplify the impact of our efforts. In addition,
    public/private-sector partners can help respond where--in areas
    where the U.S. Government has limited access or resources. And
    today at the State Department, we hosted an excellent public-
    private partnership event on just this topic.
        The State Department is committed to protecting the safety
    and security of all U.S. citizens. This also means working with
    other governments to attack the Zika virus outbreak at its
    source. By cooperating with other countries on Zika public-
    health emergency response and planning, we help build a
    stronger global response to protect U.S. citizens and the
    international community while contributing to international
    stability. If we can control an infectious outbreak quickly,
    either at home or abroad, we help limit its impact on U.S.
    citizens.
        So we are working with other governments to increase
    surveillance and diagnostic capacity, to scale up vector
    control, and to cut off the transmission cycle. We are pushing
    out across multiple platforms the information needed for our
    citizens and nationals to make informed travel decisions and to
    help to protect them from contracting Zika while overseas on
    the basis of CDC guidance. This is particularly true in the
    case of the Olympics in Brazil, where we expect over 100,000
    U.S. citizens to attend. And Brazil is working very hard to
    protect the health and safety of all athletes and spectators
    attending the Olympics and Paralympics, including through its
    own public awareness campaigns and vector-control efforts.
        Zika, like Ebola before it, has highlighted how
    interconnected we are as a global community. We have a window
    of opportunity to address the urgent needs now, before we put
    at--we are put at further risk, by working with our
    international partners and reaffirming leadership in the
    region. As Secretary Kerry said at the Global Health Security
    Agenda Summit in 2014, in an interconnected world, we invest in
    global health, not simply as a matter of charity or as a matter
    of moral responsibility, but we do it as a matter of national
    security.
        Thank you for your consideration, and I welcome the
    opportunity to answer any questions you may have.
        [Ambassador Garber's prepared statement follows:]

                     Prepared Statement of Judith G. Garber

        Chairman Rubio, Ranking Member Boxer, and distinguished Members of
    the Subcommittee, thank you for the opportunity to testify today on the
    international Zika virus outbreak response and the U.S. Department of
    State's contribution to those efforts.
        Forty countries and territories in the Western Hemisphere,
    including the Commonwealth of Puerto Rico and the U.S. Virgin Islands,
    are currently experiencing active, mosquito-borne transmission of the
    Zika virus. Several countries and territories in Africa and Asia are
    also experiencing outbreaks for the first time, including outbreaks of
    the epidemic strain circulating in the Americas. It is likely only a
    matter of time before we experience local transmission in the
    continental United States and Hawaii as well.
        In the short time since this epidemic began, international science
    and medical experts--my colleague Dr. Frieden foremost amongst them--
    have sought to understand the truly devastating impacts that this virus
    can have on its victims, and particularly on developing fetuses. It
    will be years before we know the full extent of what physicians are now
    calling ``Congenital Zika Syndrome.''
                       impacts on the western hemisphere
        This is a silent outbreak: We do not see hospitals full of ill
    patients or ambulances in the streets, but across the hemisphere,
    pregnant women and their partners are living in fear--fear that their
    child may be born with severe developmental defects, fear that they
    cannot do enough to protect their families, and fear that they will be
    unable to financially care for a child suffering from Congenital Zika
    Syndrome. The Brazilian government has reported a surge in children
    born with microcephaly or other central nervous system defects; many
    more could be affected across Central and South America and the
    Caribbean this summer.
        In addition to the tremendous emotional and health toll this
    epidemic has had on families and communities, the demographic and
    economic consequences are still emerging. In the longer term, the cost
    of lifetime support for children affected by Zika as well as adults
    experiencing Guillain-Barre Syndrome or other neurological effects
    could significantly tax national health and educational systems. Areas
    with high poverty levels and dense population are most vulnerable to
    Zika infection, but also least able to manage the consequences. Even
    with government assistance, affected families, and particularly women,
    may face economic hardship.
                  mitigating the consequences of the outbreak
        Countries around the world look to the United States as a leader in
    global health security, and we are working with countries in the
    Americas and other international partners to provide targeted,
    customized support to those affected or threatened by the virus.
        As a result of strong development progress in the region in recent
    decades, countries have strong public health systems and governments
    capable of mounting a response to Zika. Countries such as Brazil,
    Panama, and Colombia host respected research institutions with which we
    are partnering to learn more about the virus and develop
    countermeasures. Yet the ubiquity of the mosquito vector and its
    resilience against traditional vector control methods poses a
    tremendous challenge to governments and international organizations
    seeking to contain the outbreak. Through regional institutions such as
    the Pan-American Health Organization (PAHO), the Organization of
    American States (OAS), the Caribbean Public Health Agency (CARPHA), and
    the Inter-American Development Bank (IDB), the U.S. government and our
    neighbors are leveraging our collective expertise to share best
    practices, define priorities, and identify innovative tools for vector
    control and disease diagnosis.
        Other countries such as Haiti, El Salvador, Guatemala, Honduras,
    and the Dominican Republic will benefit from more direct assistance to
    effectively respond to the Zika virus threat and help prevent
    congenital infection. This includes capacity building and training for
    vector control, support for social and behavior change communication,
    support for family planning and maternal and child health interventions
    and services delivery, surveillance, disease detection, and monitoring
    and evaluation. Our embassies are working with these governments and
    international organizations to identify key capacity gaps and
    prioritize assistance.
        U.S. voluntary contributions and cooperation with the World Health
    Organization and other multilateral partners also stimulates global
    donors and amplifies the impact of our efforts. Crucially,
    multilateral, non-governmental, and private sector organizations can
    help extend response efforts to areas where the U.S. government has
    limited access or resources.
                            protecting u.s. citizens
        Cooperating with other countries on Zika public health emergency
    response and planning helps build a stronger global response to protect
    U.S. citizens and the international community, while contributing to
    international stability. If we can control an infectious disease
    outbreak quickly, either at home or abroad, we can help minimize the
    spread within the United States and limit its impact on U.S. citizens.
        Millions of U.S. citizens live and travel overseas within the
    Western Hemisphere each year, including U.S. government employees and
    military personnel. The State Department is committed to ensuring the
    safety and security of all U.S. citizens, and utilizing all available
    platforms to provide the information they need to make informed travel
    decisions and protect themselves from mosquito bites and other forms of
    Zika transmission while overseas. The U.S. government must also take a
    pro-active approach, working with host governments to increase
    surveillance and diagnostic capacity, to scale up vector control, and
    to cut off the transmission cycle by providing information and access
    to voluntary family planning services, mosquito repellants, and other
    personal protective commodities.
        With the Olympics and Paralympics coming up in Brazil, we
    anticipate that over 100,000 U.S. citizens will attend. All travelers
    to the Olympics should follow the recommendations outlined in the CDC's
    travel notice. Brazil is working very hard to protect the health and
    safety of all athletes and spectators attending the Games in Brazil,
    including through public awareness campaigns and vector control efforts
    at Olympic sites. The Brazilian Government has also emphasized that the
    Olympic Games will take place during Rio de Janeiro's winter, when the
    population of mosquitos is low. On June 14, the World Health
    Organization, at the third meeting of the International Health
    Regulations Emergency Committee on Zika, concluded that there is a very
    low risk of further international spread of Zika virus as a result of
    the Olympic and Paralympic Games. The WHO and the CDC have stated
    available evidence does not indicate there would be any meaningful
    public health impact from altering the schedule for the Games. The CDC
    recommends that pregnant women not attend the Olympics.
                                   conclusion
        The United States is fortunate to have forewarning of the tragic
    outbreak that continues to spread northward. Zika, like Ebola before
    it, highlights how interconnected we are as a global community and
    shines a spotlight on the urgency with which we must fill the gaps in
    our collective preparedness. We have a window of opportunity to address
    the urgent needs now, before we are put at further risk, by working
    with our international partners and reaffirming our leadership role in
    the region. As Secretary Kerry said at the Global Health Security
    Agenda Summit in 2014, ``in an interconnected world, we invest in
    global health not simply as a matter of charity or as a matter of moral
    responsibility, but we do it as a matter of national security.''
        Thank you for your time and consideration. I welcome the
    opportunity to answer any questions you may have.

        Senator Rubio. Thank you.
        Dr. Frieden.

      STATEMENT OF DR. TOM FRIEDEN, DIRECTOR, CENTERS FOR DISEASE
                CONTROL AND PREVENTION, ATLANTA, GEORGIA

        Dr. Frieden. Thank you very much, Chairman Rubio, Ranking
    Member Boxer, members of the committee.
        With your permission, I will submit the written statement
    for the record.
        CDC works 24/7 to protect Americans from threats. We use
    the best of modern science. Zika is both unprecedented and
    tragic. Never before have we known of a situation when a single
    mosquito bite could result in a devastating birth defect. The
    top priority in the response to Zika is to protect pregnant
    women. We are literally learning more about Zika every day,
    and, in the 6 months of our response, we have learned and done
    a number of things to protect Americans better. We wish we had
    a more rapid and robust support for funding to do even more. I
    will go through those ten things very quickly.
        First, the Zika response is extraordinarily complex. We
    have almost every center at CDC involved, more than 1,000 of
    our top scientists--this involves our Birth Defect Center, our
    vector-control work, our laboratory work, obstetrical work,
    information on sexual transmission, mosquito control, virology,
    laboratory production--to identify the best methods in each
    community to protect pregnant women.
        Second, it is now definitive that Zika causes both
    microcephaly and other severe birth defects, and that it does
    so whether or not the infected pregnant women--woman had
    symptoms of Zika during the infection. This led us to rapidly
    issue travel guidance, literally within days of first seeing
    the Zika virus in the brains of infants who had died from the
    Zika infection, and to provide guidance and education to
    providers and women of childbearing age and their partners.
    With additional resources, we would be able to better
    understand the mechanisms of that harm and the full range of
    harm. We do not know what happens to infants born with normal-
    sized heads to mothers who were infected with the Zika virus,
    and we may not know that for months or years, but we need to
    begin those studies now.
        Third, as mentioned, asymptomatic illness in pregnancy can
    cause a birth defect. And that is why we have very detailed
    guidance for what doctors should do for testing of pregnant
    women who may have been exposed.
        Fourth, Zika almost certainly causes the Guillain-Barre
    syndrome. We will know more soon. A variety of infections cause
    Guillain-Barre syndrome. It would not be a surprise for Zika to
    be associated with that. The really new and different thing
    about Zika is the connection to birth defects. As a result,
    with other parts of the Department of Health and Human
    Services, we are planning for an increase in the number of
    cases in Puerto Rico and possibly elsewhere.
        Fifth, we recognize that diagnosing Zika is hard, but we
    have made lots of progress. CDC laboratory experts have created
    the tests that are being used in more than 100 laboratories
    around the United States and nearly 100 countries around the
    world. We have produced nearly 1 million test-kit materials for
    testing. And we have identified more about how to do that more
    accurately. However, testing for Zika is difficult. Viral loads
    tend to be low in serum, and we have learned that more is
    needed to do a better job testing. There is currently no test
    that can determine whether someone had Zika infection months or
    years before. We need to accelerate work on that basic
    question.
        Fifth, sorry, sixth vector control is even harder. The
    mosquito that causes Zika is difficult to stop. We see that, in
    Puerto Rico, the mosquitoes are resistant to just about all of
    the most common insecticides used. It is critically important
    that we strengthen mosquito monitoring and control in the U.S.,
    in the territories, and learn more about how to do a better job
    stopping mosquitoes from spreading. This is something which
    additional resources would be very helpful in.
        Seventh, there are other routes of transmission. It is also
    the first time we have identified a mosquito-borne disease that
    can also be sexually transmitted. And that has implications for
    the sexual partners of women who are pregnant. So we have had
    additional guidance there. It is also clear that it can
    potentially be spread through blood. So we have worked
    carefully with the FDA, with the blood banks of the U.S., to
    ensure that the blood supply is safe in this country.
        Eighth, Puerto Rico is being singled out by the mosquito.
    Today in Puerto Rico, dozens and potentially as many as 50
    additional pregnant women will become infected with the Zika
    virus. Puerto Rico has been dealt a difficult hand because of
    its environment, and it is critical that we do everything we
    can to protect pregnant women there now.
        Ninth, globalization and urbanization are driving the
    spread of Zika, as well as cholera, yellow fever, and other
    diseases. It is the latest in a series of unpredicted and
    unpredictable health threats. What is predictable is that we
    will have new health threats, and we need a way to respond
    rapidly and robustly to identify problems where they first
    emerge, and stop them when they first come out.
        And tenth, we have seen a remarkable capacity within CDC
    for innovation--new laboratory tests, new mosquito-control
    methods. Every day, we are discovering new ways, better ways to
    protect, detect, and respond to Zika. We are committed to
    ensuring that the American people have the most accurate, up-
    to-date information.
        And I look forward to answering your questions.
        [Dr. Frieden's prepared statement follows:]

                     Prepared Statement of Dr. Tom Frieden,

                                  introduction
        Good morning Chairman Rubio, Senator Boxer, and members of the
    subcommittee. Thank you for the opportunity to testify before you today
    on Centers for Disease Control and Prevention's (CDC's) efforts to
    prepare for and respond to the Zika virus outbreak, which threatens the
    United States and the rest of the Americas.
        The administration has requested approximately $1.9 billion in
    emergency funding to respond to the Zika virus outbreak in support of
    both the domestic and international response.
        CDC is the nation's health protection agency, working 24-7 to save
    lives and protect people against unpredictable threats such as the Zika
    virus. Nature is a formidable adversary, and Zika is our newest threat,
    particularly to pregnant women. CDC has some of the world's leading
    experts both in diseases spread by mosquitos and in birth defects. We
    must act swiftly to track and respond to the Zika virus, both
    domestically and globally. While we are learning more about the Zika
    virus every day, there are many things we do not know yet about Zika.
    These include our understanding the effects of Zika infection during
    pregnancy just how the virus causes microcephaly, a severe birth defect
    that is a sign of a problem with brain development, as well as the
    effects of Zika infection on the development of Guillain-Barre syndrome
    (GBS) and other possible complications. In addition to answering these
    questions, we are also working to accelerate optimal mosquito control
    strategies, improve laboratory testing and assure preparedness for
    rapid detection, control, and prevention within the United States and
    U.S. territories.
        We are making advances in these areas and need the additional
    requested funding to do so. Much of what we know about Zika and similar
    viruses today is based on the work that's been done by CDC scientists.
    We are learning more about Zika literally every day, and will share
    information--and adjust our guidelines and recommendations--as we learn
    more. That is the nature of a scientific response to an emerging health
    threat. The doctors, scientists, laboratory experts, entomologists,
    disease control specialists, and others at CDC and other key Department
    of Health and Human Services (HHS) agencies are working nonstop to
    protect Americans from this and other health threats. We are committed
    to providing the American people with the most accurate and timely
    information about Zika virus, the current outbreak, and about what to
    expect here in the continental United States.
        It's very important that Americans remember the core prevention
    message: If you're pregnant, you should not travel to a place where
    Zika is spreading, and if you are pregnant and in a place where Zika is
    spreading, do everything you can to avoid mosquito bites. In addition,
    if you are pregnant, you should either refrain from sex with a partner
    who has been in an endemic area or use a condom every time you have sex
    during your pregnancy.
        Most people infected with Zika virus appear to have no symptoms,
    and most of those with symptoms have only mild symptoms such as fever,
    rash, joint pain, and red eyes or conjunctivitis--that last no more
    than a week. Zika virus infection is, however, a cause of microcephaly
    and other severe fetal brain defects and is associated with serious
    health outcomes for babies of women infected during pregnancy, even
    when the woman has no symptoms. In addition, Guillain-Barre syndrome
    has been reported following Zika virus infection, although a causal
    link has not yet been definitively established. CDC is investigating
    the link between Zika and GBS. GBS is very likely triggered by Zika in
    a small proportion of those infected, much as it is after a variety of
    other infections.
        CDC's key priority in responding to this epidemic is to reduce the
    risk of Zika virus infection to pregnant women. CDC is acting based on
    what we know and, at the same time, undertaking research to better
    prevent adverse health outcomes in the future. That's why, during the
    same week we identified Zika in brain tissue specimens, CDC advised
    pregnant women not to travel to affected areas.
                                 current status
        While we have not yet seen transmission of the Zika virus by
    mosquitoes within the continental United States, many returning
    travelers to the US have been infected with Zika virus. As of July 6,
    1,132 cases of travel associated Zika virus infections have been
    reported in US states and the District of Columbia. Also, as of July 6,
    2,534 cases of Zika virus infections associated with mosquito-borne
    local transmission have been reported in the US territories, mostly in
    Puerto Rico. During the same timeframe, 320 cases of Zika virus
    infection have been reported among pregnant women in the United States
    and 279 infections have been reported among pregnant women in US
    territories. We know also, that a small number of cases can be
    attributed to sexual transmission.
        CDC is also reporting the outcomes of pregnancies with laboratory
    evidence of possible Zika virus infection in the U.S. states, DC and
    the territories. As of June 30 there have been seven live born infants
    and five pregnancy losses with birth defects reported to CDC's US Zika
    Pregnancy Registry. As of the same date, one pregnancy loss with birth
    defects has been reported by the territories to either the US Zika
    Pregnancy Registry or to the Puerto Rico Zika Active Pregnancy
    Surveillance System.
        CDC urgently needs a surge of resources to prevent and control the
    spread of Zika virus in the U.S. Commonwealth of Puerto Rico and the
    U.S. Virgin Islands, and other U.S. territories. The population of
    Aedes aegypti mosquitos, the primary vector for Zika virus infection,
    is widespread on these islands. Protective environmental factors such
    as window screens are not as prominent in the territories, and the
    density of people puts people there at high risk for transmission. All
    three areas have already reported local mosquito-borne Zika
    transmission. CDC has deployed staff to the U.S. Virgin Islands,
    American Samoa, and Puerto Rico to support response activities and
    provide technical assistance to health departments there.
        Furthermore, Aedes mosquitos are found in many areas of the
    continental United States, raising the risk of local transmission.
    Recent clusters of locally-transmitted dengue virus disease in the
    United States reinforce that Zika outbreaks in the continental U.S. may
    be relatively small and localized due to protective factors like window
    screens and less dense living conditions. However, any local outbreak
    will be of deep concern to the people living there, and we must be
    prepared for different scenarios including more extensive transmission
    risk. Local transmission of Zika will occur when a mosquito bites
    someone who is infected with Zika, likely someone infected during
    travel to a Zika-affected areas, and later bites another person,
    spreading the virus. There are about 40 million people travelling
    between the continental U.S. and Zika-affected areas each year.
                               what cdc is doing
        WHO has declared Zika a public health emergency and pregnant women,
    especially, need to be protected from its effects. To prevent and track
    Zika virus infection, CDC is conducting surveillance of the spread of
    the virus, developing and distributing better diagnostic tests, working
    with states and localities to improve mosquito control and tracking,
    assisting Puerto Rico and other territories, issuing travel guidance,
    and providing clinical guidance on Zika. CDC experts are also working
    to protect pregnant women by better understanding the link between Zika
    infection and adverse health outcomes.
        Surveillance is essential to monitor and quickly identify areas
    with local transmission. Most of CDC's surveillance for arboviruses,
    including Zika, is captured through ArboNET, an integrated network
    which is used to monitor incidence of disease, conduct human case
    investigations, collect and test mosquitoes, and perform laboratory
    analysis. CDC's Epidemiology and Laboratory Capacity Cooperative
    Agreement supports ArboNet, including funding staff in 49 states,
    Puerto Rico, and six large municipalities. Zika infection is now a
    nationally notifiable disease, meaning states report all identified
    cases of Zika infection to CDC.
        While we know Zika infection causes microcephaly and other fetal
    anomalies, we do not fully understand how, or if, there are important
    cofactors for these adverse outcomes. CDC is working to improve our
    understanding of the spectrum of effects of Zika infection during
    pregnancy (i.e., whether children born with normal-sized heads might
    have other neurological damage, which may not be apparent for months or
    years), just how the virus causes microcephaly, the duration of Zika
    infectivity in semen, and why some but not all women infected during
    pregnancy give birth to infants with microcephaly. A child born with
    microcephaly can cost up to an estimated $10 million to care for over
    their lifetime, and can have devastating effects on families and
    communities who must care for them. In addition to surveillance for
    Zika cases, CDC is working with the states and territories on
    surveillance of pregnancies with evidence of Zika infections and
    pregnancy outcomes through the U.S. Zika Pregnancy Registry and the
    Puerto Rico Zika Active Pregnancy Surveillance System. These are unique
    and unprecedented systems which can monitor pregnant women and their
    families and support health departments which provide care to these
    families. CDC is also planning a prospective cohort study in Colombia
    to evaluate the risk of maternal, fetal, and neonatal complications of
    Zika infection in pregnancy according to when during the pregnancy the
    infection occurred. This study will complement an ongoing multi-country
    study supported by the National Institutes of Health (NIH) to evaluate
    the magnitude of health risks that Zika virus infection poses to
    pregnant women and their developing fetuses and infants.
        CDC, along with other HHS agencies and private sector partners, has
    worked around the clock to develop and ship diagnostic tests to detect
    Zika virus infection. CDC currently has two different Emergency Use
    Authorizations (EUAs) from the Food and Drug Administration (FDA), one
    for the MAC-ELISA test, which measures the body's immune response to
    the virus (issued February 26, 2016 and reissued on June 29, 2016) and
    the other for the Trioplex rRT-PCR assay, which identifies the acute
    presence of the virus (issued March 17). These tests have been
    distributed through the CDC Laboratory Response Network (LRN). The LRN
    is an integrated network of domestic and international laboratories
    that can respond to biological and chemical terrorism and other public
    health emergencies. In addition to use in the United States, many other
    countries were provided the CDC assays necessary to run these tests. In
    the United States, Zika diagnostic tests are now also available through
    commercial laboratories. CDC is working to increase laboratory capacity
    in the United States to handle the surge capacity needs posed by the
    Zika virus. CDC remains open to collaboration and assisting partners,
    including private industry, in their endeavors to bring accurate and
    precise Zika diagnostic assays to market.
        Many states and localities have existing mosquito control programs.
    CDC provides technical expertise on mosquito control strategies,
    including the best methods to control immature and adult mosquitoes,
    monitor resistance to insecticides, conduct mosquito surveillance, and
    monitor efficacy of control efforts. Expanded capacity has also been
    provided to states through the Epidemiology and Laboratory Capacity for
    Infectious Diseases Cooperative Agreement, Public Health Emergency
    Preparedness Cooperative Agreement, and federal vector control
    contracts to extend mosquito surveillance and control. In collaboration
    with the U.S. Departments of Defense, Agriculture, and Homeland
    Security, as well as the Environmental Protection Agency, HHS is
    working across its Operating Divisions to accelerate mosquito control
    research and to coordinate response efforts in the territories, as well
    as in the continental United States and Hawaii.
        Puerto Rico has a particular challenge when it comes to vector
    control and mosquito-borne disease. Dengue and chikungunya, which are
    spread by the same mosquito, have spread rapidly throughout the island,
    and insecticide resistance is common. Now, dozens of pregnant women are
    infected every day with Zika virus, and we are very concerned about
    what the coming months will hold. We are working with our partners in
    the Puerto Rico government, private industry, and other federal
    agencies to reduce the risk from mosquitoes spreading Zika in the
    territory. Activities include using CDC-developed mosquito traps,
    conducting indoor and outdoor residual spraying, distributing personal
    protection tools to pregnant women in Zika Prevention Kits, and
    amplifying our public education efforts.
        CDC has issued 49 travel notices related to Zika. These are Level 2
    travel health notices, advising travelers to practice enhanced
    precautions, with additional guidance for women who are pregnant or are
    trying to become pregnant. Pregnant women should postpone travel to
    regions with ongoing Zika virus transmission. If they must travel, or
    if they live in affected areas, CDC recommends pregnant women talk to
    their doctors or other healthcare providers first and to prevent
    mosquito bites. Reducing exposure to mosquitoes is important for anyone
    traveling to or residing in areas where the virus is circulating.
    Wearing long sleeves, long pants, using EPA-approved repellents such as
    DEET and permethrin-treated clothing (both of which are safe to use
    during pregnancy), and using other protections such as air-conditioning
    and window screens will reduce exposure to daytime mosquitoes. Given
    the potential for Zika virus to be spread through sex, pregnant women
    and their male partners living in or who have been to Zika-affected
    areas should abstain from sex or use condoms for the duration of the
    pregnancy.
        CDC also has provided guidance for doctors and other clinicians on
    evaluation, treatment, and follow-up care of pregnant women and infants
    with possible exposure to Zika virus, partnering with organizations
    from the health care community to help distribute this information as
    widely as possible.
        This is a rapidly changing situation and our understanding of the
    risks concerning Zika virus infection is incomplete and evolving. As we
    get new information, we will update our advice.
                         coordination and partnerships
        CDC is working closely with health departments across the country
    and in the territories to support and coordinate its efforts and to
    expand capacity for detecting and responding to Zika virus. Strong
    collaboration with states and local partners is critical to an
    effective response. CDC is helping states assess and expand capacity,
    while engaging stakeholders including healthcare providers, blood
    banks, vector control organizations, medical associations, schools,
    employers, and others. We are continuously refining and improving our
    recommendations based on issues identified during the CDC-hosted Zika
    Action Plan Summit for state and local health officials and continued
    feedback from states.
        I also want to acknowledge our federal partners. I have mentioned a
    few already. CDC is working in collaboration with other components of
    HHS including the Office of the Assistant Secretary for Preparedness
    and Response (ASPR) and its Biomedical Advanced Research and
    Development Authority (BARDA), the Office of the Assistant Secretary
    for Health, the NIH, who are working to develop a vaccine, and the FDA
    We are also working with partners across the U.S. Government, including
    the Department of State, the Department of Homeland Security, the
    Department of Veterans Affairs, and the Environmental Protection
    Agency, to communicate with travelers and health care providers, update
    travel alerts and clinical guidance, and develop improved mosquito-
    control methods.
                                 olympic games
        CDC and the United States Olympic Committee (USOC) signed a
    memorandum of understanding on May 27, 2016, and are working together
    to communicate risks and protective actions that can be taken before,
    during, and after travel to the 2016 Olympic Games in Brazil. The
    target audience for CDC's outreach efforts include Olympic and
    Paralympic athletes, staff, and delegation members. Our guidance for
    the general public for travel to the Olympics is the same guidance we
    have issued for travel to Brazil and other areas with Zika. While many
    Americans will travel to Brazil for the Olympics, travel to the
    Olympics is only a small fraction of overall global travel to countries
    that have ongoing Zika transmission. Travel to the Olympic Games
    represents about 0.25 percent of total aviation travel annually to
    Zika-affected areas.
        CDC's communication actions for the Olympics include webinars to
    National Governing Body staff to share Zika prevention and travel
    health information, hosting an in-person informational booth during
    out-processing in Houston, co-branded print materials tailored to the
    U.S. delegation, a customized CDC website with content tailored to
    National Governing Body needs, social media messages disseminated
    through USOC channels, and short videos on packing clothing for
    prevention.
        In addition to Zika prevention guidance, CDC also has posted
    general guidance for all travellers to the 2016 Summer Olympic and
    Paralympic Games in Brazil. Guidance for travel to the Olympics
    includes information about travel vaccines, safe food and water
    practices, and safety and security in crowds.
        As we continue to learn more about the Zika virus, we will update
    our guidance and recommendations for the 2016 Olympic and Paralympic
    Games as appropriate.
                                   conclusion
        The emergence and reemergence of health threats, including those
    spread by mosquitoes and other vectors, will continue for the
    foreseeable future. These outbreaks cannot be expected to occur in
    isolation. Puerto Rico and Hawaii were already responding to outbreaks
    of dengue when Zika virus emerged as an urgent health threat. We need
    to address the threat of mosquito-borne diseases systematically, rather
    than episodically.
        While we need congressional action on the President's funding
    request, CDC has not waited for Congressional action to respond to the
    threat posed by Zika. We have made difficult decisions and redirected
    resources from other important public health activities to support our
    most critical needs. These redirected funds, however, are not enough to
    support a comprehensive Zika response, and they divert funding from
    other critically important public health activities. They only
    temporarily address what is needed until the Congress acts on the
    Administration's emergency supplemental request. Without the full
    amount of requested emergency supplemental funding, many activities
    that need to start now may have to be delayed or stopped within months,
    or may not occur at all. We need to start now to do the work to better
    understand the link between Zika disease and birth defects; track the
    spread of mosquitoes in the U.S. and control them before the epidemic
    spreads here; support states and territories to prevent and manage
    cases of Zika, diagnose patients, and increase lab capacity; and better
    understand, develop, and more fully deploy laboratory testing and for
    mosquito control.
        We are hopeful that Congress will work quickly to fund critical
    response efforts to protect pregnant women against Zika.

        Senator Rubio. Thank you, Dr. Frieden.
        Ms. Koek.

    STATEMENT OF IRENE KOEK, ACTING DEPUTY ASSISTANT ADMINISTRATOR,
       U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT, WASHINGTON, DC

        Ms. Koek. Thank you, Chairman Rubio, Ranking Member Boxer,
    and distinguished members of the subcommittee, for inviting me
    here today to testify on USAID's response to the Zika virus
    outbreak. I want to thank you for your continued leadership and
    commitment to this issue.
        I will submit a written statement for the record, but today
    I would like to briefly describe USAID's work with the U.S.
    Government and regional international partners to address Zika.
        Our aim is to minimize the negative pregnancy outcomes
    associated with Zika infection. Our efforts are focused on
    countries at risk for adverse outcomes from Zika that have
    relatively weaker government capacity to respond to Zika and
    where we expect that governments will want support from the
    United States. Our top-tier priorities include Haiti,
    Guatemala, El Salvador, Honduras, and the Dominican Republic.
        Our strategy has four interconnected lines of effort:
    vector control, social and behavior change, service delivery
    related to maternal and child care and family planning, and
    innovation.
        In vector control, our activities aim to improve and expand
    existing vector management efforts in Zika-affected or at-risk
    countries to reduce the Aedes mosquito populations. We will
    implement household and community-level vector control, helping
    those at risk learn to eliminate sources of standing water in
    which the Aedes mosquitos breed, scrub containers for mosquito
    eggs, and apply larvicide to water sources that cannot easily
    be eliminated.
        For social and behavior change in community engagement
    approaches, put the community at the forefront of managing
    their risks, and prevention and management of the disease, and
    are of critical importance. We will give people the tools and
    knowledge to adopt personal protection, protective behaviors,
    including the use of repellents, long-sleeved clothing, and
    condoms, seek care, and help with community response.
        Our service delivery approach begins before a woman becomes
    pregnant by ensuring that women in Zika-affected areas who may
    wish to delay or limit future pregnancies can access family-
    planning information and services. For women who are currently
    pregnant, providers must be trained to counsel them and their
    partners on the need to prevent sexual transmission of Zika
    through condom use. Once a woman becomes pregnant or has a baby
    in a Zika-affected area, USAID is committed to ensuring that
    she receives cost-effective, high-quality maternal and child
    health services, with an emphasis on respectful care of
    pregnant women and infants with suspected congenital Zika
    syndrome.
        Innovations are critically needed to mitigate the spread
    and impact of Zika virus and improve our ability to prevent,
    detect, and respond to future infectious disease outbreaks.
        While we are utilizing all the tools in our toolbox to
    mitigate the impact and spread of Zika virus, many of those
    tools have limitations. As such, USAID worked quickly to launch
    a new Grand Challenge called Combating Zika and Future Threats.
    We received over 1,000 responses and believe we have some very
    exciting options. We expect to begin making awards by the end
    of this month or in early August.
        So far in our programming efforts, we have completed a new
    interagency agreement with CDC and transferred $78 million to
    enable them to start on critical surveillance and research
    activities. And we have obligated $18 million to partners to
    work primarily in service-delivery and behavior-change areas.
    We are also working with UNICEF and PAHO in the region and with
    the World Health Organization in Geneva to address growing
    needs on a global level and outside of the western hemisphere.
    By the end of this month, we expect to begin our vector-control
    activities. In August and September, our community engagement
    activities will be rolled out.
        We have designed our efforts to ensure they solidify the
    legacy of USAID's 50-year history of health assistance gains in
    the region. USAID is committed to addressing the Zika virus
    outbreak of today and strengthening capacities to ensure that
    this threat will be mitigated as much as possible.
        Thank you for the opportunity to speak with you today. I am
    happy to answer any questions.
        [Ms. Koek's prepared statement follows:]

                        Prepared Statement of Irene Koek

        Thank you Chairman Rubio, Ranking Member Boxer and distinguished
    members of the subcommittee for inviting me here today to testify on
    the U.S. Agency for International Development's (USAID) response to the
    Zika virus outbreak. I want to thank you for your continued leadership
    and commitment to global health and global development issues. We see
    you as partners in USAID's mission to end extreme poverty and promote
    resilient, democratic societies while advancing our security and
    prosperity.
        Zika cases currently have been identified in 49 countries, 40 of
    them in the Americas. More than 298 million people live in Zika-
    suitable transmission zones within the Americas. In 2015, over 5.4
    million births occurred in these environmentally suitable areas and
    during times of year when transmission is most likely to occur.
    Additionally, summer peak travel between the United States and the
    countries of Central America, and the Caribbean coincides with peak
    seasonal mosquito abundance. We do not yet know the extent to which
    pregnant women or their children in much of the region have been
    affected. While there is still a great deal to understand about Zika,
    and the current set of tools we have are limited, there is still much
    we can do to help those at risk protect themselves and reduce the
    impact of Zika on pregnant women and their babies.
        Today, I would like to briefly describe USAID's work at country,
    regional and global levels with partners in the U.S. government and
    with regional and international partners, I will also share with you
    some of the opportunities and challenges that we are all facing.
        USAID has been working closely with partners across the U.S.
    government to implement our collective response to the Zika outbreak.
    This collaboration aims to minimize the number of pregnancies affected
    by Zika virus transmission. Together, U.S. government agencies plan to
    undertake surveillance efforts to identify the progression of the Zika
    virus, diagnose infections when they occur, provide care and support
    for pregnant women who have been identified as having contracted the
    Zika virus, and take efforts to prevent further infections. We are also
    working jointly to accelerate innovation and research across each of
    these categories of response.
        Most of these international efforts are being undertaken with $211
    million that USAID reprogrammed from the planned Ebola response effort.
    Of that total, USAID has provided $78 million to our colleagues at the
    Centers for Disease Control and Prevention (CDC) to capitalize on their
    expertise in surveillance, laboratory testing, public health response,
    and entomology to ensure accurate detection of infections and
    evaluation of Zika control measures. We also count on CDC to leverage
    key research studies and evaluations that will help us better
    understand this virus. While Dr. Frieden may provide more details on
    these efforts, I think it is important to highlight the value of
    learning as much as we can about the virus. Each new piece of evidence
    allows us to more effectively shape our responses. For example, when we
    initially planned our response to Zika and submitted the
    Administration's request for additional funding, we were unaware of the
    relative risk of sexual transmission. Now, armed with that information,
    we know that our efforts must target both pregnant women and their
    partners in order to be effective, and we have adjusted our plans
    accordingly.
        With the balance of $133 million, USAID is working through existing
    country systems to reduce the risk of new infections, particularly in
    pregnant women, and provide care to those known to be affected. USAID
    has a long history of supporting countries in Latin America and the
    Caribbean, which culminated with technical assistance to ensure that
    health systems could be responsive to changing circumstances. In many
    cases, we successfully concluded nearly 50 years of assistance through
    a deliberate process that was designed to ensure that countries could
    effectively continue to advance the health of their populations. We
    know that in many of these countries, inequities exist and that hard
    wrought gains can be easily damaged by an economic or political crisis.
    For example, USAID's health program in Honduras is successfully
    concluding this year, having been extended from its original end date
    as a result of instability constitutional crisis that occurred as we
    were just beginning our phase-out plan. Our focused efforts over the
    last five years of this graduation process successfully resulted in a
    16 percentage point increase in women delivering their babies in
    healthcare facilities. Yet, the Honduran government still has more work
    to do; there is a 40 percentage point gap between the rate at which the
    richest women deliver in a facility when compared to the poorest women.
    Bearing this in mind, our response to Zika will seek to further support
    and strengthen country systems, including those responsible for
    ensuring pregnant women have access to quality prenatal care.
        We have designed our efforts to ensure that a short-term focus on
    mitigating the impact of Zika does not undermine systems, but rather
    solidifies the legacy of USAID's impressive health assistance gains in
    the region. Efforts that both strengthen host country systems and
    impact Zika require a more narrow focus to ensure a strategic use of
    available resources. We want to ensure that all efforts relate directly
    to minimizing the negative pregnancy outcomes associated with Zika
    infection. We will do this by improving the quality of Zika prevention
    and care services through both public and private sector delivery
    channels and also by ensuring that communities are engaged with
    implementation of measures that will reduce the risk of Zika infection
    in pregnant women.
        USAID's response is focused on four interconnected lines of effort:
    Innovation, Vector Control, Social and Behavior Change Communication,
    and Service Delivery related to: family planning, antenatal and
    postnatal care, as well as child development and care for families with
    infants affected by Zika. I will briefly present our programs and
    approach in each of these areas:
    Vector Control
        Our activities aim to improve, expand, and focus existing vector
    management systems, networks, and programs in Zika-affected or at-risk
    countries to reduce Aedes mosquito populations. Preliminary findings
    from vector control capacity assessments in our priority countries
    indicate that the capacity of national vector control programs to
    conduct surveillance and vector control activities is weak and
    investments are needed to improve public health entomology and protect
    pregnant women. These assessments will be finalized in August 2016 and
    we will have concrete recommendations that will inform and direct our
    partners' activities in this area. However, based on the preliminary
    results, we plan to support regional trainings and technical assistance
    to bolster inclusion of quality vector control approaches into national
    vector control programs, while monitoring mosquito populations for
    resistance to insecticides and to determine the effectiveness of vector
    control interventions. Through our community engagement efforts, we
    will implement household-to-household vector control in atrisk or
    affected communities. Specifically, households will learn how to
    eliminate sources of standing water in which Aedes mosquitoes breed and
    scrub containers for mosquito eggs. Larvicides will be used in standing
    water sources that cannot be easily eliminated. We will purchase and
    distribute the required vector control commodities to public and
    private sector partners, and we will build country capacity to conduct
    GPS mapping of breeding sites, which will provide us with information
    to forecast areas at heightened risk of transmission in real time.
    Social and Behavior Change Communication
        Social and behavior change communication and community engagement
    approaches put the community at the forefront of managing their risks
    in prevention and management of the disease. We have learned from
    previous emerging disease outbreaks that effective risk communication
    and community engagement from the outset and throughout the course of
    public health emergencies is essential for effective disease control.
    As an example, we saw that in order to control the recent Ebola
    outbreak, strengthening clinical services alone is not enough. We
    expanded our work with communities to better understand their cultural
    practices, including traditions around burial practices. By actively
    engaging communities and understanding local cultural practices, we
    were able to encourage safer behaviors, while still respecting
    community traditions and long held beliefs. These social and behavioral
    interventions, combined with effective biomedical interventions, played
    a key role in effectively controlling the outbreak.
        In order to tackle the worst effects of Zika, we will also need to
    earn the full engagement of at-risk communities so they are committed
    and effective partners in prevention and control activities. Our
    approach is aimed at enabling communities, households and individuals
    affected by and at risk of Zika to better understand their risks and
    practice key protective behaviors to minimize negative pregnancy
    outcomes. The overall approach will work through global, regional,
    national, and local levels to implement effective social and behavior
    change interventions designed to minimize negative pregnancy outcomes
    by focusing on the most at risk and vulnerable audiences: pregnant
    women, women of reproductive age and their partners, in households and
    communities in lower resource settings. With community involvement and
    the benefit of local perspectives, we will use the most appropriate
    channels to encourage behaviors for personal protection including use
    of repellents, long-sleeved clothing and condoms, to promote
    prevention, community response and care-seeking. These activities will
    be closely monitored for effectiveness and adjusted based on the
    results of that monitoring. Effective messages and approaches will be
    shared region-wide.
    Service Delivery
        In order to truly mitigate the impacts of this virus, we must
    improve access to healthcare services for women of reproductive age in
    Zika-affected or at-risk communities. These services include antenatal
    and postnatal care, child development, and family planning services. A
    key component of improving access to services is improving providers'
    capacity to deliver quality Zika-related healthcare and social services
    to women of reproductive age, particularly pregnant women, families,
    and children affected by Zika. Although most countries have issued Zika
    care guidelines, the rapid evolution of the evidence base requires
    constant updating of the guidelines, and the need for more specific
    protocols and procedures.
        Our service delivery approach begins before a woman becomes
    pregnant by ensuring that women, adolescents, and couples in Zika-
    affected areas who may wish to plan to delay or limit future
    pregnancies can access information, services, and methods regarding
    family planning. We must reach women who are considering becoming
    pregnant, and may wish to delay or limit pregnancies; as well as women
    who have unmet need for family planning, and want to prevent unintended
    pregnancies. For women who are currently pregnant, providers must be
    trained to counsel them and their partners on the need to prevent
    sexual transmission of Zika through condom use.
        Once a woman becomes pregnant or has a baby in a Zika-affected
    area, USAID is committed to helping her receive cost-effective, high
    quality maternal and child health services, with an emphasis on
    respectful care of pregnant women and infants with suspected congenital
    Zika syndrome. Therefore, our work will focus on strengthening
    antenatal care services for all pregnant women including counseling on
    prevention (repellents, condoms, and other measures) and validating
    women's fears and concerns. Within this, we will have a special focus
    on strengthening antenatal care and delivery services for women with
    suspected Zika infection during pregnancy, including psycho-social
    support for the family and specialized newborn care at delivery.
    Through policy-level engagement, USAID will work with partners and with
    host countries to improve awareness of Zika-linked health conditions in
    children and ensure the engagement of all relevant ministries including
    education, family welfare, etc. for the care and support of Zika-
    affected families and children.
        At the present time, we are not planning to focus our resources on
    care for children born with Zika congenital syndrome. However, this
    could become a growing area of need if we are unable to mount an
    effective response as soon as possible. As the need for this population
    becomes more evident or with additional resources, we will explore the
    effects of congenital Zika syndrome for infants with suspected cases,
    including the application of basic neurodevelopmental monitoring and
    therapy including early stimulation.
    Innovations
        While we are utilizing all the tools in our toolbox to mitigate the
    impact and spread of the Zika virus, many of these tools have
    limitations to their effectiveness and scalability. Aedes mosquitoes,
    for example, are less susceptible to standard vector control approaches
    like indoor residual spraying, as they tend not to rest on the walls
    where insecticides would be typically sprayed. They also can breed in
    the smallest of containers--even a plastic water bottle cap--rendering
    large-scale larvicide approaches impractical. Available products to
    protect individuals from being bitten require frequent replenishment or
    reapplication and often are unappealing to end users, due to factors
    like smell, skin or eye irritation, and comfort. And, few homes,
    schools, or other buildings have screens on their windows. As a result,
    USAID has partnered with colleagues from across the U.S. Government--
    from BARDA, CDC and NIH to the Departments of Defense and Homeland
    Security--to identify promising innovations under development within
    each agency and figure out how to bring cutting-edge technological
    advances to the developing country context. Within USAID we worked
    quickly to launch a new Grand Challenge, called ``Combating Zika and
    Future Threats,'' to enhance our capabilities in both the short and
    long term by sourcing innovations that mitigate the spread and impact
    of the Zika virus and improve our ability to prevent, detect, and
    respond to future infectious disease outbreaks, like Zika. We sought
    solutions--from new ways to reduce mosquito populations, to new options
    for preventing mosquitoes from biting or transmitting Zika to humans,
    to entirely new ways to detect and respond to Zika infections. We
    sought creative ways to educate and mobilize entire communities--from
    entrepreneurs, scientists, engineers, students, and others around the
    world. We received an overwhelming response, with nearly 1,000 ideas
    from over 60 countries, and we are moving rapidly to identify those
    ideas with the most promise for curbing the current Zika outbreak and
    preventing such outbreaks in the future.
        Unfortunately, current resources do not allow USAID to implement
    these response efforts region-wide. We cannot even implement them in
    all areas most at-risk for Zika. We have chosen to focus our efforts on
    countries at risk for adverse outcomes from Zika due to predicted
    number of cases (based on experience with dengue and chikungunya), with
    relatively weaker government capacity to respond to those cases, and
    where we expect that local governments will want robust support from
    the United States. These countries include Haiti, Guatemala, El
    Salvador, Honduras, and the Dominican Republic. Within these countries
    we believe that we can rapidly scale up to full implementation of our
    strategic set of anticipated activities and maintain these programs for
    several months. However, without additional resources, we would be
    forced to choose between cutting off programming before it can have
    lasting impact in our priority countries or eliminating any impact
    beyond the priority countries. For example, in the next set of
    countries USAID would work with, which includes Nicaragua, Jamaica,
    Paraguay, and Peru, we planned to fund technical assistance and support
    at the national level across the range of intervention areas. Without
    additional funds, these plans would need to be reconsidered against the
    consequences of stopping programs too soon in the first set of
    countries.. Our ability to truly have an impact on the spread of Zika
    is limited if we cannot cover more at-risk areas.
        We were appreciative of receiving Congressional support to move
    forward with the reprogramming of funds on April 26. In the month of
    May alone, we completed a new Interagency agreement with the Centers
    for Disease Control and Prevention and were able to transfer the full
    $78 million to enable them to get started on critical surveillance and
    research activities. We were also able to obligate an additional $14
    million to partners to work primarily in the service delivery and
    behavior change areas. Those partners quickly began meeting with
    Ministries of Health in the five target countries; coordinating with
    the United Nations Children's Fund (UNICEF), the United Nations
    Population Fund (UNFPA), and the Pan American Health Organization
    (PAHO) on national level communication strategies; conducting rapid
    assessments of existing tools and resources available to service
    delivery providers; assessing the capacity of countries in behavior
    change communication, service delivery, and vector control; as well as
    creating a Zika resource web platform, the Zika Communication Network
    (http://zikacommunicationnetwork.org/)--a source for global Zika
    prevention and preparedness materials as well as for research and
    development updates. In mid-June, along with partners, we kicked off a
    Zika-related discussion on the Springboard virtual platform, titled
    ``Communicating About Zika: Messaging for Pregnant Women and Women of
    Reproductive Age,'' that drew a record 700 people to the discussion,
    while tweets related to the discussion have reached over 60,000.
    Additionally, in our priority countries, USAID-supported private not-
    for-profit health organizations are developing provider training
    materials and behavior change messages at Ministries of Health request
    that will be applied in their networks and shared with the public
    sector. Both the private and public sectors are working together to
    align messages under the leadership of governments.
        Soon activities will be conducted to determine gaps in care
    processes around the availability and quality of family planning,
    antenatal and immediate newborn care in our focus countries. These
    activities will be conducted in collaboration with in-country
    universities, allowing us to better understand where needs are greatest
    and ensure that our response efforts are well aligned. At the same
    time, we are preparing to roll out online and in-person training
    courses to reach large numbers of health professionals as quickly as
    possible. We are also beginning partnership activities with UNICEF and
    PAHO in the region and with the World Health Organization in Geneva to
    address growing needs on a global level and outside of the Western
    Hemisphere. By the end of this month, we expect to be able to begin our
    vector control and entomological activities and then through August and
    September our community engagement and innovations activities will be
    rolled out.
        A four-month time period to initiate such a broad range of
    activities in countries and areas where USAID does not have ongoing
    health projects is a very fast rate of start up. In this time period,
    we will have completed the required analyses to ensure that our efforts
    comply with environmental safeguards and standards, we will have
    established new awards through full-and-open competition and made
    necessary modifications to other awards in order to accommodate the
    Zika response efforts. The current timeline means that we will not
    achieve full implementation until the end of the typical rainy season
    in Central America and the Caribbean. However, we are still confident
    that these resources and additional resources made available in the
    near future will allow us to be prepared with programs in place in
    order to have an immediate impact on next year's rainy season and the
    upcoming rainy season in South America. And finally, the efforts I have
    described will serve to strengthen country health systems and allow us
    to leverage this strength for improved impact.
                                   conclusion
        USAID is committed to addressing the Zika virus outbreak of today
    and strengthening capacities to ensure that this threat will be
    mitigated as much as possible. Thank you for the opportunity to speak
    with you today and to share the contributions we are making. I am happy
    to answer any questions.

        Senator Rubio. Thank you all for being here.
        I want to begin with Secretary Garber. The--Brazil's new
    Health Minister has said that there is a almost-zero risk of
    athletes or spectators contracting Zika during the Olympics. Is
    this threat--is the threat in Brazil truly almost zero? And
    what advice do you feel--let me ask this. Should our athletes
    or spectators feel fully safe in traveling to Brazil for the
    Olympics, given what we know about the situation there?
        Ambassador Garber. Thank you very much, Mr. Chairman.
        We are putting out the guidance based on the CDC guidance,
    and pushing that out through all available platforms to make
    sure that travelers and the over 100,000 Americans that are
    planning on attending the Olympics can make informed decisions.
    We know the Government of Brazil is working very hard to
    address this outbreak through its own very aggressive public
    information campaigns and vector-control efforts, including
    through many in the Army, hundreds of thousands, as well as
    public health officials to work on vector control. But I would
    defer to Dr. Frieden, specifically, on the assessment of the
    risk.
        Senator Rubio. Well, Dr. Frieden, is the chance of
    contracting Zika in Brazil almost zero for athletes and
    spectators?
        Dr. Frieden. We recommend, for any travel, that pregnant
    women not go to areas where Zika may be spreading. We would
    recommend, for the Olympics, as we would for any other travel,
    that pregnant women not travel. For others, there are
    reasonable steps people can take to protect themselves.
    Historical data does suggest that viruses spread by this
    mosquito are less common in the period of the Olympics, but we
    think the key issue is not why people travel, but who is
    traveling. And the key message to get out there is that
    pregnant women should not be traveling to areas where Zika is
    spreading, and, if they are present in those areas, should take
    steps to protect themselves.
        Senator Rubio. Well, let me ask it another way. Should
    athletes or spectators traveling to Brazil at least think about
    it before they go, given what we have known about how rapidly
    it has spread there?
        Dr. Frieden. All travel involves risk. It may be from a
    motor vehicle crash, it may be from infectious diarrhea, it may
    be from dengue or other diseases. We do not think the risk will
    outweigh the travel benefits for most people, except for the
    group of pregnant women. And that is why immediately after
    identifying Zika in the brains of affected infants, we advise
    that pregnant women not travel to Zika-affected areas. Also
    important for men who have sexual partners who are pregnant to
    use condoms if they come back from an area with Zika.
        Senator Rubio. Dr. Frieden, what is a reasonable timetable
    to expect a vaccine for Zika?
        Dr. Frieden. We are told by the National Institutes of
    Health that they hope to be in clinical trials in September.
    That would mean that, in the next couple of years, we could
    have an approved vaccine that is both safe and effective. But
    only time will tell whether that happens. It is very promising.
    The immune response to Zika is robust, so it is certainly
    theoretically quite possible, but these things do take time.
        Senator Rubio. You touched upon it in your statement
    earlier. And a lot of the focus on Zika, and rightfully so, has
    been through the impact that it has on microcephaly. But let me
    ask you--I know that there is a study ongoing with the
    Colombian government to study the link between Zika and
    Guillain-Barre. Is there anything you can share with us about
    the preliminary findings? I saw, in your statement, you said
    that you most certainly believe that it will prove that there
    is a direct link.
        Dr. Frieden. We have seen several studies published--one
    from French Polynesia. We have work going from Brazil. We
    expect, by the end of the summer, to finalize that work. I
    expect that that link will be proven, given the epidemiological
    patterns, but we do not yet have two really strong, independent
    studies determining it. That takes some time. But we have had
    excellent collaboration, both in Brazil and especially in
    Colombia, where we are really working side by side with long-
    term collaborators there.
        Senator Rubio. And again, just to be clear, just so anyone
    who might be watching this now or later would understand, the
    Guillain-Barre link is on everyone. Anyone infected by Zika
    runs that risk, beyond what we are talking about now with
    pregnancy, correct?
        Dr. Frieden. That is correct. It tends to increase with
    age, but anyone can be affected, and it can cause paralysis
    that can be severe, is usually temporary, can last from weeks
    to months.
        Senator Rubio. And, Ms. Koek, you--generally speaking, the
    health systems in Latin America and the Caribbean are stronger
    than those of many sub-Saharan African nations and Southeast
    Asian nations. And this phenomenon has prompted USAID to
    graduate several countries from any global health programs. But
    there are some groups that have come to us that are concerned
    that Haiti and countries in the Caribbean and in the northern
    triangle of Central America may be ill-equipped to handle Zika
    cases as well as possible related complications. What direct
    support, if any, are you planning to provide these countries?
        Ms. Koek. Thank you very much for that question, Senator.
        USAID has a long history of supporting countries in the
    region, and, as you noted, we did graduate our assistance from
    many countries. And that was a--following a very deliberate
    effort and working very closely with the governments and local
    partners to move away. And, as you noted, it was probably
    because of the progress that had been made in many of those
    countries, and the capacity had been developed.
        Haiti is still a country where we have a robust health
    program in all areas. And so we believe Haiti needs additional
    support. But as part of our program, they have already been
    able to move some of the resources they have through the USAID
    program to get a little bit ahead and start to respond to Zika.
        Similarly, one of the things we are doing, particularly in
    Central America, which is home to a number of our priority
    areas, is identifying where some of those gaps are. Zika was
    completely unexpected, and it does present a threat that has
    been discussed here today, figuring out where we can fill those
    gaps and provide the support needed.
        Senator Rubio. Well, are there any countries that we--that
    have graduated from the USAID health programs, have been
    graduated in their levels, that have, nonetheless, appeared to
    need additional support as a result of Zika?
        Ms. Koek. Yes. Some of the countries that we have
    prioritized, including Honduras, El Salvador, and the Dominican
    Republic, are all countries that we have graduated assistance
    from, or the robust assistance. Those are countries we believe
    do need some additional targeted support.
        Senator Rubio. Senator Boxer.
        Senator Boxer. Thank you, Mr. Chairman.
        Earlier this year, El Salvador issued a nationwide call for
    women to avoid pregnancy for 2 full years. Now, one can debate
    how real that could be, given what we know. But setting that
    aside, other governments in Latin America also called on
    women--not on men, on women--to avoid pregnancy. In other
    words, they did not tell the men that they should work with the
    women. Very typical. Other governments in Latin America and the
    Caribbean issued similar directives, including Colombia,
    Ecuador, and Jamaica. Those countries said, ``Women, do not get
    pregnant for 2 years.''
        My question to any of you on the panel, do you believe
    these countries have the health infrastructure to give women in
    these countries, who have been told not to get pregnant for 2
    years, access to free contraception?
        Ms. Koek. Thank you very much, Senator Boxer. It is a
    excellent question, and we very much share the concerns you
    raised in asking this question.
        We are very committed to ensuring that women do have access
    to all the information and support and access to services. And
    there certainly are gaps.
        Senator Boxer. That is not my question.
        Ms. Koek. Yes.
        Senator Boxer. I asked you if those countries who have told
    their women not to get pregnant for 2 years have the
    infrastructure to get free contraception to these women of
    childbearing age?
        Ms. Koek. Yes.
        Senator Boxer. They are the ones who are in charge of their
    own countries. They are the ones who issued this directive to
    their women. Do they have the infrastructure?
        Ms. Koek. I think it is a mix. Part of our graduation
    strategies in many of these countries was to make sure there
    was a strong family planning program in place, including a
    supply of contraceptives.
        Senator Boxer. Do all these countries have the ability to
    get free birth control to women of childbearing age? Do they
    have the ability to do that?
        Ms. Koek. I think, in most cases, they have supply; but the
    issue of making sure that you are not telling women that you
    must use family planning or, as you put, putting the onus on
    the women, is certainly part of what we want to make sure
    happes.
        Senator Boxer. I am not asking about that. I am asking you
    if they have the infrastructure and the ability to get
    contraception to the women that they have told that they should
    not get pregnant for 2 years. Or do they need our help getting
    that birth control to them?
        Ms. Koek. We believe the issues are mostly around the
    delivery. And that is where they do need some help. They do not
    need help on supply of contraceptives. It is the delivery that
    presents a problem, making sure that those who are most in need
    have access.
        That is where the gaps are.
        Senator Boxer. How are they doing it, the ones that you say
    are doing a good job? How are they getting this contraception
    to the people who need it?
        Ambassador Garber. If I could just provide two examples,
    Senator Boxer, and then I will defer back to Irene for anything
    additional. I am aware that, in Ecuador, for example, the
    government, through its public hospital system, does provide
    universal access to birth control. There is a delivery system
    in place to allow for that.
        And I was just in El Salvador last week and met with the
    Minister of Health there and talked a little bit with Irene's
    colleagues from USAID about how they want to prioritize the
    assistance that we are going to be giving them. And one of the
    things that the Minister of Health really emphasized
    tremendously was trying to be able to provide access to birth
    control.
        Senator Boxer. What assistance are we going to give those
    countries who have told their women not to get pregnant for 2
    years? What are we doing to provide them with free birth
    control?
        Ms. Koek. We are doing a couple of things. One is to make
    sure that the supplies that are in place are actually getting
    to the people that need them, and that there is full access,
    and that information is available to the women so they can make
    the choices themselves. There is some policy work also to make
    sure the statements that you described are--it is not
    necessarily going to help give access, and that is one of the
    concerns we have.
        Senator Boxer. Okay. How many cases are there in El
    Salvador?
        Dr. Frieden. We would have to get back to you with the
    exact number.
        Senator Boxer. Would you do that?
        Dr. Frieden. We do know that it is only a small number of
    the total cases that have been diagnosed.

        [The information requested had not been received at the
    time this document went to press.]

        Senator Boxer. Good. And what about Colombia, Ecuador, and
    Jamaica? Do you have those stats?
        Dr. Frieden. Offhand, no, but the reported numbers are, in
    most countries, only a small fraction of the total cases, since
    80 percent of people have no symptoms at all and testing is not
    widely available in many of these countries.
        Senator Boxer. Well, how many babies have been born with
    anomalies in those countries? Do you have that data?
        Dr. Frieden. In Brazil, where the epidemic started, you
    have had the largest number of pregnant women with infections
    in the first trimester, which appears to be the highest-risk
    period to come to term. And we have seen between hundreds and
    thousands of babies with microcephaly. Those are still under
    investigation, in terms of confirmation of the diagnosis. We
    have an investigation collaboratively with Colombia, where we
    are following a group or cohort of women who appear to have had
    Zika infection. And over the coming months, we will be able to
    determine with more certainty what the prognosis is.
        Senator Boxer. Could you get back to me on the numbers of
    those countries where the countries have stated they have given
    this directive to the women and girls not to get pregnant for 2
    years, those countries I mentioned, how many cases of anomalies
    they have had?

        [The information requested had not been received at the
    time this document went to press.]

        ]Senator Boxer. I was telling the Chairman that I heard a
    report on one of the radio news shows that--and I just do not
    know if this is anything you are involved in or we are involved
    in--that, for the young men and women who are going to Brazil,
    that they are going to be tracked afterward and followed to see
    what happens with their health. Could--do you know anything
    about that?
        Dr. Frieden. We have a memorandum of understanding with the
    U.S. Olympics Committee. We work collaboratively providing
    technical assistance, outreach, and education. They are also
    working with a university in the U.S. to do a study voluntarily
    for athletes and members of the Olympics and Paralympics who
    want to know, both before and after, whether they might have
    been infected. That might have been what that was referring to.
        Senator Boxer. Okay.
        Well, let me just say, if we know this is dangerous, so
    dangerous that we are asking these people to volunteer, we
    better talk to these people, one by one by one by one by one by
    one, and let them know how serious this is. I feel very
    strongly about that. I do not want our people being used as
    guinea pigs, ``Oh, you come home, we will follow you, we are
    going to see whether you got this or not, and how--if you had
    any babies who have microcephaly.'' This is not right.
        I would just close my frustrating comments here today by
    saying that we cannot have one hand tied behind our back by
    saying, as the House said in a completely partisan way, none of
    this money could be used for nongovernmental entities to help
    provide birth control, which is so critical. And it is wrong--a
    country thinks they solved the problem, when they just tell the
    women in the country they should not become pregnant. There is
    something wrong about that on so many levels. And I hope we
    will let them know more about this.
        And lastly, for our young people who are going to go to
    Brazil, where there are all these problems. I understand that
    they are spraying; they are doing everything, and I am very
    glad about that. There is a whole other issue of whether it is
    even morally responsible to have the Olympics. That is not our
    job to discuss, but it is happening. And we are now going to
    track our people voluntarily to see whether they get this
    disease, whether there is something amiss. I would just
    encourage us to reach out to these athletes very clearly. If
    the risk is so great that you are going to spend money
    following them, maybe they ought to know it.
        Senator Rubio. Before I turn it over to Senator Isakson,
    are we providing our Olympic athletes a basic kit of repellent
    and whatever they need to take with them in order to prevent
    the disease, the contraceptives, whatever it is? What are we
    providing them? Are we working with the Olympic Committee to do
    so?
        Dr. Frieden. Yes. We are working with the Olympic Committee
    to provide both information and materials for the athletes for
    each of the different sports that are participating, each of
    the different associations.
        Senator Rubio. Okay.
        Senator Isakson.
        Senator Isakson. Thank you, Senator Rubio. And thanks, to
    you and Senator Boxer, for calling this very important hearing.
        I want to issue an invitation to the four members that are
    here. In recent weeks, I have had the chance, with Dr.
    Frieden's courtesy, to host two members of the United States
    Senate at CDC in Atlanta. And I would urge you to come down and
    spend an afternoon, and I will spend it with you, to see the
    research that is done and the reach that CDC has, particularly
    with regard to Zika.
        I want to underline, CDC is always referred to as the
    Center for Disease Control, but it is a five-word title, not a
    three-word title. It is Center for Disease Control and
    Prevention. And we are at a critical point on Zika, where we
    are--the prevention needs to be what we focus on, because
    controlling it does not do you any good once these cases start
    multiplying.
        I will give you some numbers for us to be aware of. The
    urgency of this matter is this: that, as of July the 6th, there
    are 1,133 Zika cases in the continental United States of
    America, and 320 are pregnant women, as of June the 30th. Is
    that about correct, Dr. Frieden?
        Dr. Frieden. Yes.
        Senator Isakson. In the U.S. territories, there are 2,534
    cases, and 279 are pregnant women. This is a crisis of major
    proportion, and we--time is of the essence.
        I have made two or three speeches on the floor, talking
    about the need for us to pass this. And it will be professional
    malpractice on our part if we leave here for 7 weeks and have
    not dealt with this, because Dr. Frieden and the Center for
    Disease Control and Prevention need the funds now to prevent
    what could be a major worldwide crisis, in terms of the Zika
    pregnancy.
        As a Georgian, just as an anecdotal piece of evidence, an
    employee of mine attended the briefing with Senator Collins
    that Dr. Frieden gave us on Zika a few months ago. His wife was
    in an early pregnancy. After the briefing, he moved his wife to
    Colorado, where these mosquitoes do not exist, just to be sure
    she is in a safer environment than Georgia during the term of
    her pregnancy. In our State, the two mosquitoes that are
    carrying the Zika both are indigenous to Georgia.
        So, this is something that is priority one, as far as I am
    concerned. And I think it is critical that we get it done now.
        I walked my dear friend Senator Boxer, whose passion I have
    seen illustrated on thousands of issues as we work together as
    co-chairs of the Ethics Committee, but when you came in, you
    mentioned the Confederate flag. I want you to know that, as
    Chairman of the Veterans Committee, I saw to it that the Senate
    took out the House provisions, and there is nothing in the
    conference report at all that deals with the Confederate flag.
    Correct, Tim?
        Senator Boxer. That is not our understanding.
        Senator Isakson. I see Tim nodding his head. I can tell
    you, I have the jurisdiction. I took care of that.
        Senator Boxer. Okay. Because I was just informed that it is
    in there, so let us go look at it.
        Senator Isakson. Well, as Chairman, I am telling you it
    is--if it is in there, somebody went over my head, because I am
    the one that made sure that Senate provision provided--
    prevailed, which was: No provision at all.
        Senator Boxer. In the military bill.
        Senator Isakson. Well, I am talking about the Zika bill we
    are talking about. It is not in there.
        Senator Boxer. Okay. I will double check.
        Senator Isakson. I appreciate it.
        Senator Boxer. I was just briefed today on that.
        Senator Isakson. But I want to underline the fact that this
    is about prevention. And we can have our differences on a lot
    of things, but we have got to do everything we can to get the
    resources in the hands of the CDC to develop a program of
    prevention.
        They demonstrated it on Ebola. The thing about Ebola that
    they get so much credit for, and should, is the Ebola outbreak
    took place, people developed Ebola, and they got out there and
    they treated people with Ebola. The number of deaths was
    minimized, but what people forget about is, the educational
    reach of CDC around the world to teach people best practices
    actually stopped the epidemic within a pretty unbelievable
    period of time. I think, about 13 to 16 weeks, if I am not
    mistaken. And that is what we want to see with Zika. We do not
    want to just deal with those that have it. We want to deal with
    those that do not have it, and make sure they do not get it.
    And this funding is absolutely critical for us to see to it
    that that happens.
        So, Senator Rubio, calling this hearing today and focusing
    on the need to do it is very important. And I hope, before we
    leave tomorrow, we can have an agreement in the Senate to
    ratify the conference report.
        And I want to thank all of you in healthcare for what you
    do to help protect the pregnant moms of America and the
    citizens of my State against what is a real threat. And the
    problem is, it is a delayed reaction. You find out today that
    they are pregnant; 9 months from now, you find out if there is
    a problem. And 9 months from now is too late. We need to
    prevent every terrible pregnancy we can today, and that is why
    I want to focus on the need to pass this as quickly as possible
    in the United States Senate.
        I yield back. That was not a question. That was a speech,
    and I apologize. [Laughter.]
        Senator Boxer. It was a good one.
        Senator Rubio. Senator Kaine.
        Senator Kaine. Thank you, Mr. Chair. And I am going to do
    some speeches and some questions.
        You know, this is such a serious problem, but this is also
    an illustration why a lot of people hate Congress. They hate
    Congress. And this is nothing bad on my Senate colleagues. We
    had some differences of opinion about this Zika, how to deal
    with it. And so, we voted on three different Zika provisions.
    There was a Democratic provision to deal with Zika that did not
    get enough votes. There was a Republican provision about how to
    deal with Zika that did not get enough votes. And then there
    was a bipartisan provision about how to deal with Zika that did
    get enough votes. And there were some things in it that
    probably one side did not like, and some things that the other
    side did not like, but we got 68 votes. And it was a billion-
    one, not the number we might have liked, but we got it, and it
    was a clean bill. It was a bill about one thing: fighting Zika.
    That is what it was about.
        When it comes back to us, the bill is not about fighting
    Zika. Frankly, it is about fighting Planning Parenthood and
    paying for it by taking money out of the Affordable Care Act.
    So, we have got this massive public health challenge, and the
    American public is worried about it. And we are supposed to
    fight Zika. And that is what the Senate did. We fought Zika.
    But the bill comes back to us, and it is, ``Let us fight
    Planned Parenthood. That is more important than fighting Zika.
    Let us take money out of the Affordable Care Act. That is more
    important than fighting Zika.'' This is why people hate
    Congress. This is why people hate Washington.
        And again, this is no slight on us, because I think we
    actually reached the right compromise, but then the ``fighting
    Zika bill'' becomes the ``fight Planned Parenthood bill'' or
    the ``fight the Affordable Care Act bill.'' And it is my hope
    that we will get this thing straightened out. I know everybody
    here on this dais wants to. And I would second a point that
    Senator Boxer made in her comments. The right way to deal with
    this, probably down the road, is budgetarily to treat
    infectious diseases like we treat FEMA. We have a funding
    mechanism for FEMA. We do not know where a hurricane will hit.
    We do not know where there will be a forest fire, where there
    will be a flood. But we do know from experience that there will
    be these items, and so we budget for them and then we deal with
    them.
        We do not do that with respect to infectious diseases, and
    then that gives people the ability to play games and hold
    people hostage to try to ride their pet hobbyhorse instead of
    doing the thing that we are supposed to do.
        Couple of questions: I am curious, on the transmission. If
    you can be infected and asymptomatic, if you come back into the
    United States and you have been in an area where there is a lot
    of Zika, with respect to sexual transmission, you are telling
    males, for example, to use condoms. How long are you doing
    this? Is it for months? Is it for weeks? What is the advice
    that you are giving people when they return from Zika-infected
    areas?
        Dr. Frieden. Our current advice, based on the best-
    available information, which we continue to accrue every day,
    is that, for men whose partners are pregnant, use a condom for
    the duration of pregnancy. Because we do not know how long that
    man may remain infectious. There are studies that are underway,
    but they will take 6, 12 months to finalize.
        Senator Kaine. What advice are you giving, if any, to men
    whose partners are not pregnant?
        Dr. Frieden. For couples who are trying to conceive, our
    current advice is that, if they had no symptoms of Zika
    infection, they should wait at least 2 months after leaving the
    Zika area. And if they did have symptoms, because they might
    have more virus with that, then it would be 6 months.
        Senator Kaine. Right.
        And then, here is another kind of transmission I was not
    aware of it until recently. If you are in a Zika-infected area
    and you come back to the United States, and you have been
    bitten by a mosquito there, and you may not have symptoms, your
    blood could have Zika infection. And so, if you are bitten by a
    mosquito in the United States, that could be a blood
    transmission to mosquitoes here. What are you--what advice are
    you giving people about needing to try to avoid mosquito bites
    in the United States after they return from a country that has
    a Zika problem?
        Dr. Frieden. We encourage people to avoid mosquito bites by
    using DEET, staying indoors, staying in screened or air-
    conditioned spaces. But the scenario that you outlined is
    exactly the scenario that we think is most likely to spread
    Zika in parts of the U.S., where diseases like dengue have
    spread in the past, where we have seen clusters in parts of
    Florida and Texas through mosquito-borne transmission, although
    we have now shown that there is sexual transmission, and we
    know blood-transfusion transmission is possible if the blood is
    not screened, which is currently being screened in Puerto Rico
    and other places.
        The more likely way that it would spread in this country is
    the way it is spreading around the world, primarily, which is
    by mosquito bites.
        Senator Kaine. And so, if somebody returns to the United
    States from an area with a heavy Zika challenge, how long are
    you suggesting that it is important for that person to avoid
    getting bitten by a mosquito in the United States?
        Dr. Frieden. Three weeks.
        Senator Kaine. Okay, thank you.
        I want to ask about the vector-control piece. And I know
    the FDA has a portion of that, as well. And so, I am assuming
    that, you know, you are all working together. The vaccine is
    going to take some time to develop. So, as I understand vector
    control, it is a number of different kinds of solutions. It is
    spraying and figuring out how to do spraying. I am--I
    understand that there is various proposals on the table for
    different--you know, mosquitoes that will not reproduce. And
    so, hopefully that could reduce the density of mosquitoes in
    certain areas. Talk about the range and kind of vector-control
    solutions that you are looking at. Recognizing that the vaccine
    is down the road, what can we do right now to reduce the
    density of mosquitoes that would be carrying this disease?
        Dr. Frieden. So, these are very tough mosquitoes to
    control. They are referred to as ``the cockroach of
    mosquitoes.'' They live indoors and outdoors. They bite in the
    daytime and the evening. They readily develop resistance to
    insecticides. They have co-evolved with people in urban areas,
    so they are an urban pest.
        The control measures, I would put into two large
    categories. One is proven safe and effective methods, but they
    have not been put together in a way that is effective to stop
    the mosquito. And we need to figure out how to use our existing
    tools better. And then new tools, experimental things like
    sterile male technology, where you release sterile males and
    try to crash the mosquito population. Both of these things
    require more effort. We need to try the different methods out
    there and see how rapidly, how persistently we can reduce the
    mosquitoes. The recommended approach is an integrated vector-
    management approach, where you reduce standing water, you
    reduce larvae, and you use judiciously adulticides or
    pesticides to kill the adult mosquitoes. On a longer timeframe,
    more like the vaccine, or even longer than that, is the new
    tools. We need new insecticides, we need new ways to control
    mosquito populations. But we have to move forward rapidly in
    both of these areas.
        Senator Kaine. And could I just--my time is up, but one
    last question--or maybe two quick ones.
        On the--both of these--developing the vaccine takes a
    tremendous investment, but also the vector-control solutions,
    both to research to determine which are best, and then to
    deploy them broadly, that is also not cheap. That takes a
    significant investment, correct?
        Dr. Frieden. That is correct.
        Senator Kaine. Those are all the questions I have. Thank
    you.
        Thanks, Mr. Chair.
        Senator Rubio. Thank you.
        Senator Gardner.
        Senator Gardner. Thank you, Mr. Chairman.
        And I apologize, I am not going to be able to use my full
    time here. That might not need an apology, but I am not going
    to be able to use it all. I have to go preside over--on the
    floor, here, soon.
        Dr. Frieden, I wanted to talk to you a little bit about the
    CDC work. Of course, Fort Collins, Colorado, is home to the
    Division for Vector-Borne Diseases and has done a tremendous
    amount of work at this location on vector-borne illnesses, such
    as Chikungunya, dengue, and Zika virus. And I was fortunate
    enough to have the opportunity to visit the work concerning
    Zika virus there at the laboratory in February of this year,
    including going in to look at the live mosquitoes, the larvae,
    and what was happening, and how the whole process worked.
        I learned, at this time, about a chemical called nootkatone
    that the CDC was working to reclassify as a biochemical
    pesticide active ingredient. Nootkatone is a--according to this
    tour, was a natural ingredient, I think, found in citrus, like
    grapefruit oil. It might be in some cedar trees, as well, but
    it has a natural grounding. Many may recognize this from their
    shampoos. I think this product is in many shampoos, as well.
    The EPA has to evaluate natural tick repellents and pesticides
    for registration before they may be sold for use by the public,
    to validate safety and efficacy. Has your agency--how have you
    coordinated with other agencies to expedite the approval of
    various products, nootkatone or others, to ensure they become
    available?
        Dr. Frieden. Thank you very much, Senator. And we are
    delighted to--that you had the chance to visit our unit out in
    Fort Collins, Colorado. It is the lead unit for Zika and for
    this work. They do phenomenal work. Their innovation has been
    terrific. They have come up with the new and now increasingly
    available laboratory tests to diagnose Zika. They have also
    overseen the work in our dengue branch, which has come up with
    some new means of capturing mosquitoes and tracking
    populations.
        The chemical you refer to, nootkatone, has been under
    evaluation for years at Fort Collins, and we have recently
    licensed it to several companies. We are working very closely
    with the EPA so that it could be brought to market as quickly
    as possible. It is food grade, generally recognized as safe,
    nontoxic, appears to be as effective as DEET against both
    mosquitoes and ticks. We are running out of different classes
    of insecticides. This appears to work in a totally new manner.
    So, we do not know, in the end, whether it will work out, but
    it is certainly very promising. We have had a good reaction
    from EPA that is willing to work with us and with the companies
    to get it to market as rapidly as possible.
        Similarly, with the diagnostic tests, we have had excellent
    collaboration with the Food and Drug Administration, which has,
    within days, approved for emergency use the diagnostic tests
    that we have developed.
        Senator Gardner. Thank you.
        And I am going to have to go to the floor now. But are you
    familiar with the legislation that the Senate is considering
    from the House on the Zika funding? Are you familiar with the
    details of that legislation at all from the--the House-passed
    version of Zika funding?
        Dr. Frieden. Yes.
        Senator Gardner. Okay. And I would--because I hear people
    talk about the funding of Planned Parenthood. And I just want
    to make--I have a question for you on this funding. Does the
    House bill take money away from Planned Parenthood?
        Dr. Frieden. I am not familiar with the exact funding
    allocations in that bill.
        Senator Gardner. I believe the answer is no. And I would
    just--would love to--if you could get back to me on that.

        [The information requested had not been received at the
    time this document went to press.]

        ]Senator Gardner. Thank you.
        Thank you.
        Senator Rubio. Senator Kaine, you had a followup?
        Senator Kaine. Just one brief followup. Advice for all of
    us. Tell me if this is right. I understand that the mosquito
    that carries Zika breeds in containers, so not necessarily in
    standing water on the ground, necessarily, but more swimming
    pools or, you know, like the depression in the cover of my
    grill that ends up with rainwater on it, or a dog bowl in the
    backyard, a wheelbarrow. I have got one of those. I have got a
    canoe that gets water in it. So, one of the things that we can
    all do in our neighborhoods if we want to try to reduce the
    population density of this mosquito is to make sure that there
    is not water standing in containers in our yards and
    neighborhoods. Am I generally right about that?
        Dr. Frieden. Yes, you are, Senator. And one of the
    challenges of controlling this mosquito is that it can breed in
    tiny amounts of water, the amount in a bottlecap. So, to
    eliminate standing water really means eliminating all standing
    water. And that is why it has been difficult to do it to an
    extent that you will actually see a large enough impact on the
    number of mosquitoes to make a difference. But different
    communities are different. In one community, birdbaths were
    found to be one of the important sources of mosquito-breeding
    water. So, that is one reason why it is so important that
    communities in this country and around the world have the tools
    to track the numbers of mosquitoes and see if their mosquito-
    control activities are succeeding.
        Senator Kaine. Thank you.
        Senator Rubio. The bigger question is, Why do you have a
    canoe? [Laughter.]
        Senator Rubio. But we will get into that.
        Senator Markey.
        Senator Markey. Thank you, Mr. Chairman.
        Can I go to the pesticide issue and what breakthroughs we
    might be making in pesticides? Are there new pesticides that
    might be effective, that can supersede the need to use DEET or
    other pesticides? Can any of you talk about that?
        Dr. Frieden. Thank you so much, Senator.
        First off, let us divide the different types of repellents
    in pesticides. So, DEET is a product that we would put on our
    skin. There are several FDA-approved products that are
    effective. I mentioned that there are some more products down
    the road which may be available in the future, that may be more
    pleasant to use, and just as safe and effective. There are also
    products that can be used in an area, what are referred to as
    spatial repellents, so things that you might burn in your
    household or spray in your household. There, we are trying to
    get better products available. And then third are materials
    that we would use to control mosquitoes in a community, so
    insecticides or pesticides.
        One of the really interesting things that has happened in
    recent years is the refinement of ultra-low-volume spraying, or
    ULV spraying. It uses tiny amounts of the pesticide, and a very
    different particle size, to penetrate more deeply, waft down
    more slowly, kill mosquitoes more effectively at a lower dose.
    And what we are seeing with those ultra-low-volume applications
    is the ability to control mosquitoes with less pesticide but
    more efficacy.
        So, one of the areas, again, is using our current tools
    more effectively, or tweaking them, if you will. The second is
    developing new tools, like new classes of insecticide. It has
    been decades since we have had a new class of insecticide
    available. That is why funding to develop new types of
    insecticides, ensure that they are safe and effective is so
    important. That is why we are so excited about the chemical
    that Senator Gardner mentioned, nootkatone, because it is
    nontoxic, food grade. And there are also new experimental
    methods, sterile male or gene drive, that are truly
    experimental, where we might be able to crash mosquito
    populations. We will have to see whether those are scalable,
    effective, and safe. But we will not know unless we study it.
        Senator Markey. Now, this ultra-low-volume insecticide,
    have you used it in Puerto Rico?
        Dr. Frieden. That is currently under consideration.
        Senator Markey. And what would be the question that you
    would have to answer before its use?
        Dr. Frieden. The spread of Zika is so rapid and so
    extensive in Puerto Rico that it is likely that, to have an
    impact, it would have to be applied by fixed-wing aircraft or
    aerial spraying. That creates a lot of concern in Puerto Rico.
    And there has been very vocal concern about that raised. We
    think there is a gap of information, and we are working hard to
    get valid information out and to confront some myths about
    this.
        Senator Markey. So, your--the contention of the CDC or the
    U.S. Government is that this ultra-low-volume spraying can be
    done without any danger to human beings, but yet play a good
    role in helping to control the Zika fly?
        Dr. Frieden. We believe it can rapidly reduce mosquitoes,
    and both CDC and the EPA have indicated that it can be done
    without risk to people, animals, or the environment.
        Senator Markey. Down in Puerto Rico right now, you are
    saying that is being resisted because of kind of a generalized
    fear that something can be done that harms other children, I
    suppose----
        Dr. Frieden. There are----
        Senator Markey [continuing). With those kinds of
    insecticides being put into the air.
        Dr. Frieden. There are a number of concerns, a number of
    historical factors, current events, that make it a big
    challenge to do this there. But from a technical standpoint, we
    think this is the most likely way you could reduce the number
    of mosquitoes substantially and quickly.
        Senator Markey. Now, if an outbreak occurred within the
    continental United States, would this be one of the methods
    that you would recommend be used, let us say, in the first
    community that had an outbreak in order to try to isolate it
    quickly?
        Dr. Frieden. It very much depends on the conditions in the
    community. But this is something that is done routinely in the
    U.S. In fact the State of Florida, each year, uses ULV aerial
    application in about 6 million acres. It is done routinely in
    Tampa, Miami, and other places. It is unfamiliar in Puerto
    Rico, and therefore, there are some concerns there.
        Senator Markey. Yeah.
        And can I take a--just a little bit of time just to talk
    about the cost of now treating children who have contracted
    microcephaly or other diseases related to this epidemic? The
    United States is now going to have long-term responsibility for
    the care of these children. And it is going to add millions, if
    not billions, of dollars over time to the budget of our
    country. And so, this is, to me, a classic example of where
    working smarter, putting the preventative tools in place up
    front will then protect us against huge, balloon costs that
    could last 30, 40, 50, 60 years with something that we could
    have prevented from exploding into huge numbers. So, even the
    children in Puerto Rico are Americans, and we have
    responsibility for them for years to come. So, not spending the
    money there now is something that ultimately we are going to
    pay a price that is hundreds of times higher in the long term,
    in terms of providing medical care for them. Could you talk a
    little bit about that?
        Dr. Frieden. Our Birth Defect Center has documented that
    the care of one child with a severe birth defect can be up to
    $10 million, or more, in their lifetime. So, there is a
    personal tragedy, a family tragedy, but also an economic cost
    for not preventing preventable cases of birth defects. It is
    very rare to have birth defects that can be prevented in the
    dozens, hundreds, or thousands. Our staff from our Birth Defect
    Center tell us that, in the 30 years they have been working on
    birth defects, this is the most urgent situation they have
    faced.
        Senator Markey. Yeah. So, you know, the old saying is ``A
    stitch in time saves nine.'' But here a billion dollars now
    could save $10 billion later, because of all the children who
    would not ultimately be born with this disease, that we would
    have a moral responsibility, a legal responsibility, to take
    care of.
        So, I think that is something that we should all think
    about, in terms of Puerto Rico or any of the other places that
    could ultimately be affected by this disease, even if it is not
    something that happened inside the continental United States.
        Thank you, Mr. Chairman.
        Senator Rubio. Thank you.
        I--as you know, I have supported the President's request at
    1.9 billion. I thought we should err on the side of caution and
    do it as quickly as possible. I supported the 1.1, even if it
    was less, but it was something. I have been trying to urgently
    get us to do something to move funds so we can begin to address
    it.
        I was wondering if you could discuss--and perhaps this
    applies beyond simply the CDC--but what happens if, tomorrow,
    Congress adjourns for 6 weeks for the conventions and the
    summer and no funding is forthcoming? Where are the shortfalls?
    What will not be happening as a result of the inability to do
    something about this?
        Dr. Frieden. Well, I will start, and my colleagues may want
    to say more.
        We will do the best we can, but this is no way to fight
    epidemics. It means we cannot begin the long-term projects to
    figure out how to protect women more effectively, to come up
    with better ways to diagnose Zika, to accelerate mosquito
    control strategies, because we have not been able to invest in
    those things. We also will not be able to repay the money we
    borrowed. We borrowed emergency money from States throughout
    the U.S. so that we could allocate it for Zika, not because
    that money was not important or needed, because that was the
    only money we had access to that we could use rapidly. And we
    have a gap in resources to fight Ebola in West Africa, because
    we had dollars that we had planned to use, starting October 1,
    to continue to keep Ebola in control in West Africa. We are
    continuing to see flares of the embers that are burning from
    the epidemic that is over there.
        And all of those resources are at risk. That is why passage
    of a supplemental is so important, and it shows us again why
    having some sort of an infectious disease rapid-response fund
    is critically important so that we do not have to go through
    this the next time there is a global public health emergency.
    Because, without a doubt, there will be a next time.
        Ms. Koek. Yes, if I could--thank you very much, Senator--if
    I could just add to that and would certainly echo Dr. Frieden
    that we will do the best we can, but with the resources we
    have, we will be able to support the countries that I noted for
    a period of time, for several months during the next year, but
    we certainly will not be able to do very much to expand to
    other countries or really deepen the impact of our programs. It
    is enough to pay for activities running through several months,
    but we cannot expand. And we do believe we need to expand. It
    cannot just be the five countries.
        Ambassador Garber. Thank you very much, Mr. Chairman, for
    that question.
        It has impact for the State Department activities, as well.
    We hope to use the money from the supplemental for targeted
    support for U.S. citizens, such as repatriation loans for those
    that may be--U.S. citizens that may be affected, living
    overseas. As a former Ambassador, I can tell you, one thing
    that gives me great concern is that, if current trends of our
    medical evacuation of pregnant women as employees or their
    spouses in our posts overseas continue as--at the current
    rates, we do not have sufficient money for those medical
    evacuations throughout the year. This was part of the targeted
    money for that. And I think we have to take care of our own
    people. That is extremely important. And we are asking them to
    sacrifice by going overseas. We also hope to use some of that
    money for improving on communications plans in many countries
    and out to U.S. citizens.
        As we have heard in so much of the testimony today, getting
    the information out is so critical, and whether that is to U.S.
    citizens or help our embassies being able to help other
    governments get the information out--can do so much in the area
    of prevention.
        And also, last but certainly not least, it enables us to
    make contributions to international organizations, such as the
    World Health Organization. Countries look to the U.S. for
    leadership. If we are able to make those contributions, we know
    that it will stimulate other countries to do the same.
        Senator Rubio. So, just to summarize, if this money does
    not happen tomorrow, then we are--we face a situation where all
    of the innovative work going into getting ahead of this will
    not be able to move forward. In addition to the risk of an
    Ebola or other outbreak happening somewhere in the world and
    the depletion of the emergency funds at the individual State
    level, we face the inability to fund the work we are doing with
    partner nations in the region who, if they are dramatically
    impacted, ultimately will impact us, because some of those
    cases will migrate here in search of medical care and so forth
    and on a humanitarian basis.
        And what I have heard from you, Secretary Garber, you are
    saying we may not even be--have--we will run out of funds to
    actually bring our people back home from being--who are
    deployed abroad, serving in our embassies and consulates around
    the world.
        Dr. Frieden, you talked about the screening of blood in
    Puerto Rico. Are we screening blood now in the mainland, as
    well?
        Dr. Frieden. The Food and Drug Administration oversees
    blood screening in the U.S. There are parts of the U.S. that
    have undertaken screening. Other parts are waiting until they
    have local transmission or possible local transmission.
    Already, parts of Texas and elsewhere, where they have had
    dengue before, have screened. The screening tests are highly
    accurate in blood, so we want to ensure that we keep the risk
    as close to zero as possible.
        Senator Rubio. Well, I ask--from the case of Florida,
    obviously Central Florida--all of Florida, in general, but
    Central Florida, in particular, has a very strong link with
    Puerto Rico, with the island. Do you know if Central Florida is
    screening its blood supply?
        Dr. Frieden. I would have to get back to you.

        [The information requested had not been received at the
    time this document went to press.]

        Dr. Frieden. Also, already, the blood banks had, as of
    several months ago, begun a policy that people who have
    traveled to a place with Zika should defer donation. So, by
    deferring donors, that is an added layer of safety. So, people
    who have come from Puerto Rico, for example, would be told not
    to donate blood and would be asked specifically about that
    during that time.
        Senator Rubio. Here is the last question, Dr. Frieden. If
    someone contracts Zika, in most of these cases they are not
    even symptomatic, in essence. There are people who are carrying
    it today in the United States that do not even know it, either
    because you are not symptomatic or, if you are symptomatic, you
    are largely going to present at an urgent care, emergency room,
    or a doctor's office with what looks like the flu, in some
    cases, right? So, let us just use as an example if I were to
    contract Zika, the way I would manifest, if I had any symptoms
    at all, would very much mimic that of a viral infection or a
    flu, correct?
        Dr. Frieden. Correct.
        Senator Rubio. And the likelihood, even if I have traveled
    abroad, unless I reported it, or if I even showed up--because
    oftentimes I know these symptoms now, at 45 years of age. I
    have had the flu a number of times; I get the shot every year
    now, though, I have had the flu a number of times, and colds
    and what have you. And so, you would basically say, ``I know
    what I have. I will just go through it.'' The chances are that
    I may not even go to a doctor, much less be tested, because
    the--as I understand it, the screening for Zika is still not
    widely commercially available. It would require a referral to a
    Department of Health to look at it specifically. It is not the
    kind of thing you see in a panel written up in a doctor's
    office. Is that correct?
        Dr. Frieden. Yes, that is correct.
        Senator Rubio. And so, the reality is that it is very
    much--it is quite possible, and perhaps, I would dare say, even
    probable, that there is already a mosquito infection that has
    occurred in the United States, and we just do not know it,
    because that person has not yet been tested. What we do not--
    what we know is, no one who has not traveled abroad and has not
    contracted it sexually has not tested positive yet. But we do
    not know if, somewhere in the United States right now, there is
    someone who contracted it from a mosquito bite in the United
    States, but because they are not pregnant or because they are
    not symptomatic or because they were not tested, because they
    just thought they had the flu, we do not know that it was
    transmitted by a mosquito.
        Dr. Frieden. So, yes, it is certainly possible. Let me also
    say, on your blood donation question, I want to validate the
    answers I gave you before, and we will get you more information
    on that. But on testing, because, as you point out, 80 percent
    of people have no symptoms, those with symptoms have symptoms
    that are relatively mild, there is the possibility that
    transmission could occur without our recognizing it. That is
    why we are encouraging health departments throughout the U.S.
    to follow up on all known cases of Zika, and to encourage
    doctors in those areas where Zika might spread through the
    local mosquito to be alert to the possibility, and also to test
    contact or family members who have illness to see if they have
    Zika. We have also been working hard to transfer our test
    methods to the private sector. They are not there yet, though
    we have made progress toward that.
        So, I think the scenario you outlined is certainly
    plausible. We anticipate that it will be very difficult to
    identify the first locally transmitted case of Zika. This is
    why we need better diagnostics. This is why we need better
    mosquito-control programs throughout the U.S.
        Senator Rubio. Obviously, you cannot speculate entirely
    about the future, but do you have--personally, based on your
    expertise, do you have any doubt that we will see a mosquito
    transmission at the U.S.--in the mainland United States at some
    point?
        Dr. Frieden. I think it is likely we will see mosquito-
    borne transmission. We do not have a crystal ball, but the best
    predictor is what has happened with dengue. And with dengue, we
    have seen clusters and isolated cases in various parts of the
    country, particularly Florida and also Texas. So, if--since
    Zika is spread by the same mosquito, we anticipate that the
    same type of pattern may occur, in addition to the unexpected
    sexual and, potentially, other means of transmission.
        Senator Rubio. And my last question with regards to this
    is, Does it make any sense at any point in time, from a medical
    perspective, to add a test for Zika to the normal screening or
    the panel that would be administered to someone the way you
    would put some other infections or other diseases or other
    viral infections on a normal panel for a blood test?
        Dr. Frieden. At this point, probably not, for a variety of
    reasons. If, in the future, we were to have a test for prior
    infection with Zika, that might give us some useful
    information. But we know that, if you have a test applied where
    the positivity rate is low, you will have a large number of
    false positives, even if the test is a good test.
        Senator Rubio. There--I am sorry to--there is no--the only
    way to confirm a Zika diagnosis is through a blood test?
        Dr. Frieden. Blood and urine.
        Senator Rubio. So, it is--also appears in other fluids----
        Dr. Frieden. Yeah, there are two--broadly speaking, there
    are two types of tests for Zika, one that looks for the actual
    virus, the RNA of the virus. And that can be found in blood or
    urine for about the first 2 weeks, currently, after infection,
    or a test that checks for the body's reaction to the virus, the
    antibodies, and that becomes positive within the first week or
    two, and generally stays positive only for about 8 to 12 weeks.
        Senator Rubio. Yeah. And the reason why I ask only is
    because I was just wondering if, at some point, as part of the
    research that is being done, it is possible to create some sort
    of quick--painless, I suppose, if--ideally--a point-of-entry
    test that could be applied to travelers coming into the United
    States. But obviously, if it is your blood, you are asking them
    to submit to having blood drawn, which is--and having someone
    undergo a urinalysis at an airport is not the best way to
    welcome them to the United States. But--[Laughter.]
        Dr. Frieden. We have about 40 million trips to and from the
    U.S. to Zika-endemic areas, and perhaps 200 million----
        Senator Rubio. That is a lot of tests.
        Dr. Frieden.--over land or other trips. The--theoretically
    speaking, if, a few years from now, we have a good test for
    prior infection, and a vaccine, you could imagine a situation
    in which travelers leaving the U.S. would want to find out if
    they had immunity, and, if not and potentially would become
    pregnant, get a vaccine. That is very theoretical.
        Senator Rubio. We have run long, so my last question--I
    promise this is the last question.
        If someone has traveled abroad to one of these countries
    where Zika is present, and they have either had relations or
    have been bitten by a mosquito, or think they might have been,
    what--how can they--how would they get tested? Could their
    doctor order a test?
        Dr. Frieden. Any doctor in the U.S. can contact their local
    health department. We have already distributed our test, and
    trained and supervised labs around the country, so that most
    State health labs already can do this test. And those that do
    not can send it to CDC labs to have done. So, again, in the
    first 2 weeks, there is one type of test; from 2 to 12 weeks,
    another type of test. If people, particularly pregnant women,
    are concerned that they may have an infection, they should be
    tested. And people with symptoms of Zika who have traveled
    should also be tested. And those tests are available.
        As you indicate, if we could get them into the private
    sector, they would be more widely available. And we are doing
    that as rapidly as possible. We actually got Food and Drug
    Administration approval to do that, within the past week. We
    have already shipped the materials to private labs, and they
    are now undergoing the validation so that they can be
    comfortable in doing this and providing the results.
        Senator Rubio. Well, I want to thank all three of you for
    your time and for being here. And, from the attendance today,
    obviously, on the subcommittee there is clearly an interest,
    both among our members and the general public.
        Before we conclude, I would like to include a study
    conducted by the University of Florida, the finest learning
    institution in the Southeast United States--[Laughter.]
        Senator Rubio.--from Dr. Glen Morris, as part of the
    hearing record. That was a point of personal privilege.

        [The information referred to can be found in the
    ``Additional Material Submitted for the Record'' section at the
    end of this document.]

        Senator Rubio. And the record for this hearing was going to
    remain open until the close of business on Friday.
        And, with that, the meeting is adjourned.
        [Whereupon, at 4:15 p.m., the hearing was adjourned.]

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                  Additional Material Submitted for the Record

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                              Zika Virus Explained

                               February 19, 2016

                         EMERGING PATHOGENS INSTITUTE
                             UNIVERSITY OF FLORIDA

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

              Statement Submitted by the Center for Vaccines and
                    Immunology at the University of Georgia

        During the last week of June, 2016, the first person in the
    continental United States died in Utah from Zika virus infection. Zika
    is almost never fatal, however, an elderly Puerto Rican man also died
    in April from Zika virus complications. Urgent action is needed to stem
    the spread of Zika virus in the United States and throughout the
    Americas. Before 2007, very few human cases of ZIKV infection were
    reported, but now there is a full-blown epidemic and the beginnings of
    a ZIKV pandemic. On February 1, 2016, the World Health Organization
    declared the virulent Zika virus an international health emergency.
    Zika virus is spreading explosively and could affect millions people in
    the United States in the next year. This mosquito-transmitted virus is
    linked with birth defects in thousands of babies in the Americas, as
    well as Guillain-Barre syndrome, a disorder in which the immune system
    attacks the nervous system. Pregnant women are a high risk of
    complications following Zika infection.
        Currently, there is no approved vaccine against the Zika virus
    (ZIKV). However, several organizations, including the University of
    Georgia (UGA), are actively developing vaccines using various platforms
    and technologies. While many of these are in the early stages, several
    are based upon previously approved platforms and designs against dengue
    virus and other infectious disease agents. To address this challenge,
    the University of Georgia and metro Atlanta-based GeoVax have entered
    into a partnership to develop and test a potential Zika virus vaccine.
    Dr. Ted M. Ross, director of UGA's Center for Vaccines and Immunology
    and Georgia Research Alliance Eminent Scholar, is leading a team of UGA
    researchers to develop this novel Zika virus vaccine. GeoVax's novel
    vaccine platform technology takes a different approach with virus-like
    particle (VLPs) by using recombinant DNA or viruses to produce VLPs in
    the person being vaccinated so they more closely resemble the virus
    generated in a body during a natural infection. GeoVax's platform is
    focused on vaccines against HIV and hemorrhagic fever viruses,
    including Ebola. It is also being evaluated for use in cancer vaccines.
    The UGA research team focuses on designing, developing and testing
    vaccines, including those for VLPs, which mimic a live virus but don't
    contain genetic material and cannot replicate or cause infection. VLPs
    give immune systems a ``head start'' in fighting infection, Dr. Ross
    said in a statement.
        We strongly encourage the U.S. Congress to pass comprehensive Zika
    legislation for research.
                                             Ted M. Ross, Ph.D.
                       Director, UGA Center for Vaccines and Immunology

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