Highlight on Iowa: Update on West Nile, Zika, and HIV diagnoses

The Iowa Department of Public Health (IDPH) recently announced the first human West Nile virus cases of 2016, that new HIV diagnoses were up 27 percent in 2015, and that 13 Iowans were infected with Zika in summer 2016.

West Nile

The IDPH announced that testing at the State Hygienic Laboratory (SHL) in Iowa has confirmed the first human cases of West Nile virus disease in 2016. A female child (0-17 years of age) and an adult male (41-60 years of age), both of Sioux County, were hospitalized due to the virus but are now recovering. “These cases serve as a reminder to all Iowans that the West Nile virus is present and it’s important for Iowans to be using insect repellent when outdoors,” according to IDPH Medical Director, Dr. Patricia Quinlisk.

Iowans are advised by the IDPH to: (1) use insect repellent with DEET, picaridin, IR3535, or oil of lemon eucalyptus (DEET should not be used on infants less than two months old and oil of lemon eucalyptus should not be used on children under three years old); (2) avoid outdoor activities at dusk and dawn; (3) wear long-sleeved shirts, pants, shoes, and socks whenever possible outdoors; and (4) eliminate standing water around the home.

Since West Nile first appeared in Iowa in 2002, it has been found in every county in Iowa, either in humans, horses, or birds. The virus peaked in 2003, when 141 were sickened and six died. In 2015, 14 cases of West Nile virus were reported to IDPH. The last death caused by West Nile virus was in 2010, and there were two deaths that year.

Zika

According to a August 12, 2016 Zika virus update from IDPH, the mosquitoes that are transmitting Zika virus in Central and South America and threatening parts of the southern United States are not established in Iowa, so the risk to Iowans occurs when they travel to Zika-affected areas. The Centers for Disease Control and Prevention (CDC) has issued Level 2 travel alerts to Zika-affected areas advising travelers to take measures to prevent mosquito bites. Thirteen Iowans have been confirmed to have Zika in summer 2016, but all were believed to be infected while traveling in affected regions.

HIV

The IDPH annual HIV Surveillance Report for 2015 finds there were 124 new HIV diagnoses in 2015, an increase of 27 percent from the 98 cases reported in 2014. This increase marks a return to the levels seen in 2013, and is a reversal from the drop in cases from 2013 to 2014.

The IDPH speculates that since 2014 was the first year of full implementation of the Affordable Care Act (ACA), it is possible that fewer HIV tests were performed because providers were dealing with the influx of new patients, leading to fewer confirmed cases. The 2015 increase may be because providers were more prepared for the increase in patients, and were more likely to perform HIV testing. This speculation is supported by the fact that the largest diagnoses decreases in 2014 and increases in 2015 occurred in private physician offices, hospital-based clinics, and community health centers (compared to public test sites, correctional settings, and blood banks).

Of the 2,367 diagnosed persons (both in and out of care) in Iowa, 76 percent were virally suppressed.  Nationally, an estimated 42 percent of persons diagnosed with HIV (both in and out of care) had attained viral suppression, so Iowa does very well by comparison.

In addition, the IDPH reports that the number of deaths among HIV-infected persons diagnosed in Iowa continues to decrease since peaking at 103 deaths in 1995. Since 2000, the number of deaths has fluctuated from a low of 20 to a high of 44.  Preliminary data indicate 20 HIV or AIDS-related Iowa deaths in 2015.

IDPH and its community partners are currently creating Iowa’s 2017-2021 Comprehensive HIV Plan, which will be released in fall 2016.

HHS ups prevention efforts as Zika confirmed in Florida

As Zika finds its way into the mainland U.S., with the infection having been found in Miami, Florida, HHS is working toward reducing the time needed to diagnose patients with recent Zika infections. With a $5.1 million award to InBios International, Inc,, HHS is supporting the development of a serological test, which detects a Zika virus-specific Immonoglobulin M (IgM), antibodies produced by the body’s immune response to the virus.

Faster Zika testing under development

Currently, the only serological test available was developed by the Centers for Disease Control and Prevention (CDC) and is being used under emergency use authorization issued by the FDA. The test requires two to three days before results are available. Providing a faster, easier, and commercially available test to clinical laboratories would increase Zika testing capacity significantly. The funding occurs under a two-year contract with the Assistant Secretary for Preparedness and Response (ASPR) Biomedical Advanced Research and Development Authority (BARDA). The funding supports refinement of the test’s design, manufacturing preparations, and clinical studies. The agreement can be extended to fund additional work on the test through 2021 and for total funding of approximately $9.5 million.

The FDA is working closely with companies that are making blood screening tests available under an Investigational New Drug application (IND) to ensure that they are prepared to expand testing as needed. Blood collection establishments in the U.S. may choose now or in the future to participate in testing under IND, even if mosquito-borne Zika transmission has not been confirmed locally.

Zika confirmed in Florida

Florida public health officials have found persistent mosquito populations and additional Zika infections in a Miami neighborhood where several Zika infections were previously confirmed. Information suggests a continued risk of active transmission of Zika virus in the area. Florida health officials and the CDC are issuing travel advisories, testing, and other recommendations for those who traveled to or lived in the designated areas of Florida on or after June 15, 2016, the earliest known date of a confirmed Zika infection in Florida. Among other recommendations, the CDC advises that pregnant women not travel to the identified area and that pregnant women and their partners living in the area should consistently follow steps to prevent mosquito bites and sexual transmission of Zika. Male and female sexual partners of pregnant women who live in or who have traveled to the area should consistently and correctly use a barrier method during sex or abstain from sex for the duration of the pregnancy.

To protect from mosquito bites, individuals including pregnant women and women planning to become pregnant should apply insect repellant containing DEET to uncovered skin, wear long-sleeved shirts and long pants, use or repair screens on windows and doors, use air conditioning when available, and remove standing water where mosquitoes lay eggs.

Administration seeks to better align Puerto Rico’s health care with the mainland

While HHS has invested over $9.5 billion in Puerto Rico from 2009 to 2014 to improve health care systems and health outcomes of the 3.5 million Americans living in Puerto Rico, the Obama Administration seeks to do more through additional funding for Medicare and Medicaid programs and supplemental funding to reduce transmission of the Zika virus. Secretary Burwell and HHS announced that they are working closely with other members of the Administration and key stakeholders to not only address the current fiscal crisis in Puerto Rico, but to help ensure that residents of Puerto Rico get access to quality and affordable health care.

Medicaid

HHS has used available resources to help the more than 1.6 million Medicaid enrollees in Puerto Rico’s health care system, of whom 600,000 could lose their coverage when its one-time Medicaid funding run out in 2019. For example, through the fiscal year (FY) 2016 budget, HHS provided Puerto Rico and the territories access to the Medicaid Drug Rebate Program to lower prescription drug cost in Medicaid.

The Administration believes that more meaningful measures are needed that will require legislation. As such, the Administration’s FY 2017 Budget proposed three principle reforms to the Medicaid program to raise the standard of care in Puerto Rico to a level that better aligns with the mainland: (1) lift the federal cap on Medicaid funding to Puerto Rico and the other U.S. Territories; (2) immediately increase the federal Medicaid share from 55 percent to 60 percent and raise it to 83 percent over time as Puerto Rico and the other territories successfully strengthen and modernize their Medicaid programs; and (3) expand eligibility to 100 percent of the federal poverty level over time.

Medicare

The Administration’s FY 2017 Budget proposes giving the HHS Secretary the authority to adjust Medicare’s disproportionate share (DSH) payments to better account for the higher costs of low income patients in Puerto Rico. Both DSH and uncompensated care payments depend, in part, on patients being eligible for Supplemental Security Income (SSI), which Puerto Ricans do not receive. As such, HHS plans to further address the distribution of uncompensated care payments to Puerto Rico in its 2017 Inpatient Prospective Payment System (IPPS) Final rule, especially if CMS continues to determine uncompensated care payments using SSI days. HHS also plans to accelerate the alignment of the formula to pay hospitals in Puerto Rico with the formula used in the 50 states, which would increase hospital payment rates in Puerto Rico by approximately 5 percent.

Supplemental Zika virus funding

Because Puerto Rico is experiencing ongoing active transmission of Zika, on February 8, 2016, the Administration made a request to Congress for a temporary one-year increase in Puerto Rico’s Medicaid Federal Medical Assistance Percentage (FMAP). This would provide an estimated $250 million in additional federal assistance to support health services for pregnant women at risk of infection or diagnosed with Zika virus and for children with microcephaly, and other health care costs. The request would not make any changes to Puerto Rico’s underlying Medicaid program, and the additional funding will not count towards Puerto Rico’s current Medicaid allotment. Unlike the states, Puerto Rico’s Medicaid funding is capped, which gives it limited capacity to respond to emergent and growing health needs.

Other Administration efforts

Since 2009, the Administration has made the following efforts in Puerto Rico: (1) invested in expanding early childhood education and child care programs; (2) provided access to health insurance and health care services through the Children’s Health Insurance Program (CHIP) and Medicaid; (3) supported food safety and security monitoring projects; (4) helped people with disabilities and older adults to live with dignity and independence; (5) funded 20 health centers treating over 330,000 people in 2014; and (6) established eight new service delivery sites with the help of $5 million in funding in 2015.

Zika’s potential impact on abortion legislation in Latin America

The Zika virus has been a hot topic in the news, with reactions varying from panic to dismissal. The biggest concern surrounding the disease is the potential for severe birth defects in children born to women who were infected while pregnant, which has stirred up the always-controversial topics of reproductive rights and decisions.

Virus

Like dengue and chikungunya, Zika is spread through mosquito bites. The virus symptoms themselves are surprisingly mild. The Centers for Disease Control and Prevention (CDC) reports that common symptoms are fever, rash, joint pain, and red eyes lasting up to a week. Only about one in five people who are infected with the virus actually develop Zika, and those that do are simply encouraged to get rest, take acetaminophen, and drink fluids.

Where is it?

Zika outbreaks were noted in Africa, Southeast Asia, and the Pacific Islands prior to 2015. The virus was first identified in Brazil in May 2015, and has been reported in many other South American countries. Although no locally transmitted cases have been noted in the U.S., it has been brought into the country by those infected elsewhere. Local cases in Puerto Rico, the Virgin Island, and American Samoa have been detected.

The particular species of mosquito known to carry Zika, Aedes aegypti, is not as prevalent in the U.S. as more southern countries because it prefers tropical and sub-tropical climates. However, some studies have found that the Aedes is common in Louisiana, Florida, some areas of Texas, and is sometimes seen as far north as New York in the summer.

Pregnancy

The major discussion surrounding Zika has stemmed from reports of a serious birth defect and “other poor pregnancy outcomes” in babies born to mothers who were infected while pregnant. Microcephaly, a condition in which a baby’s head size is significantly reduced, has been linked to the virus. According to the Mayo Clinic, microcephaly usually causes the brain to develop abnormally or fail to grow as expected, often causing developmental delays. As a result of these concerns, the CDC and other agencies recommend that women who are pregnant avoid traveling to areas where Zika is known. The first confirmed pregnancy case in Europe was recently found in Spain, where a woman recently returned from Colombia.

Controversy

The talk of Zika and potential serious birth defects has brought up a discussion regarding abortion laws, especially in heavily religious countries like Brazil where abortion is illegal in most cases. According to the New York Times, a case is already being prepared to fight for pregnant women to have the option for an abortion when microcephaly is discovered, and a judge has already expressed support for that side of the issue. Other groups are speaking up about keeping the restrictions as they currently are, or making abortions still harder to obtain. Some are recalling the legal battles in the U.S. surrounding abortions when it was discovered that contracting rubella during pregnancy would result in “damaged children”—an article published in the Wall Street Journal in 1966 sounds eerily similar to the discussion today. The Therapeutic Abortion Act, enacted during the rubella scares before a vaccine was developed, made California the first state to legalize abortion, with restrictions.

Those pushing for easier access to abortions note that contraception is particularly hard to obtain in Latin America. In addition, the culture often allows men to call the shots on how large a family becomes. Even though El Salvador’s government advised women to postpone pregnancy for two years, those studying family planning in the reason state that such actions are simply not feasible for many women—especially considering that clinics in five countries in the region exhausted their contraceptive supplies in 2015. Maternity and labor and delivery care are also hard to come by especially for the poor, resulting in many women giving birth outside of a medical facility. Sources have reported that millions of women have sought unsafe abortions in the region, often resulting in further health issues.