[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

                               __________



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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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