Managing the Zika Outbreak Among Underserved Communities

By Shuka Kalantari
Photo credit: Reuters

When a health epidemic takes root, poor and underserved communities tend to experience the most severe consequences. The mosquito-borne Zika virus, which the World Health Organization (WHO) declared a declared a public health emergency on February 1, 2016, poses similar challenges on a global scale. Here in the U.S., doctors and nurses who serve low-income and rural patients are looking to early prevention and better access to testing to stem the tide.

Underserved Communities Most at Risk for Zika

Brazil has felt the harshest effects of the Zika virus, with over 160,000 confirmed cases — the majority concentrated in Rio de Janeiro. Most of the Rio residents infected with Zika come from low-income and densely populated areas like those in the city's outskirts, where few can afford screened windows and air conditioners. In fact, WHO recommended that people visiting Rio for the 2016 Olympics "avoid visiting impoverished or overcrowded areas."

Sara Kennedy, medical director at Planned Parenthood Northern California, oversees community health centers in 19 counties. She says Zika cases in the United States will never reach the epidemic proportions of many Central American countries due to better disease control and prevention programs as well as lower poverty rates. However, as the number of cases rises in the U.S., socioeconomic factors will determine who faces the biggest risks and long-term effects.

Dr. Ellen Olshansky, chair of the Department of Nursing in the School of Social Work at USC, emphasized "the disproportionate effect of the Zika virus on people in poorer communities is a disturbing example of why we must address social determinants of health just as we address biomedical aspects of health."

"It will be harder for those who are poor, who are part of a vulnerable population or who do not speak English to access health care," Kennedy says. "They are less likely to be tested and then get into good follow-up care."

Kennedy says migrant farmworkers in states like California are at higher risk because they often travel back and forth to Mexico and Central America with their families. Health care practitioners should routinely screen these individuals for infection risks, especially women of childbearing ages, she adds.

"If those women don't have access to good family services, they are at much higher risk of suffering the severest consequences of the Zika virus," Kennedy says.

Even though low-income and underrepresented communities are the most at risk for Zika, Kennedy says the mosquito carrying the virus is indifferent to borders and socioeconomic status. Zika is a public health problem for everybody.

The Spread of Zika in the U.S.

The Zika virus comes from Aedes aegypti or Aedes albopictus mosquitoes and was discovered in 1947. In the same family as yellow fever, dengue and chikungunya, Zika was only recently associated with microcephaly, a condition where a baby's head is smaller than normal because of abnormal brain development. The link is not scientifically proven, but WHO predicts one in 100 pregnant women with Zika will have a baby with microcephaly.

As of August 24, there had been 2,517 cases of Zika reported in the United States. Of the 584 pregnant women infected in the states, 16 gave birth to children with birth defects, and five had miscarriages or abortions as of August 18. On August 4, the California Department of Public Health reported the first two cases of Zika-related birth defects in the state. As of August 18, California had 189 confirmed cases of Zika in 26 counties.

On July 29, Florida became the first state to report local transmission of Zika, but Kennedy says it won't be the last. Warm states like Florida, Arizona, New Mexico and parts of California are also at risk for local transmission.

Barriers to Screening and Prevention

There is currently no Congressional funding for Zika prevention. In April, the White House announced it would reroute $589 million of existing Ebola funds to Zika screening and prevention, but that is nowhere near the $2 billion requested by the Obama administration.

Each state is handling control of the virus differently. In Florida, Governor Rick Scott ordered the Department of Health to provide free Zika testing to pregnant women at all county health departments. New York implemented a six-step plan, including a public awareness campaign and free prevention kits for pregnant women. The state also required county health departments to submit plans on how they will control the spread and treatment of Zika.

As of May 31, the CDC recommends all pregnant women in the United States use bug spray and avoid getting mosquito bites, even outside of areas with Zika cases. The CDC also strongly suggests pregnant women have screens on windows, use air conditioning and stay indoors, but Kennedy says farmworkers and many others cannot even consider these as options.

There is no cure for Zika, nor is there a commercially available test that shows Zika exposure and the associated risks of microcephaly in pregnant women. In California, counties serve as filters for blood specimens. Each county sends collected blood samples to the California Department of Public Health (CDPH) for Zika testing, to ensure the CDC guidelines are met and the virus is accurately monitored. Currently, the CDPH in Sacramento is the only place in the state where blood samples can be tested for Zika.

Jenna Dran is the Zika response nurse coordinator at the University of California San Francisco (UCSF) Medical Center at Mission Bay. She tracks the complicated development of CDC guidelines and distributes it to her staff and patients. She ensures all Zika tests coming out of UCSF follow CDC guidelines.

Dran says there is a bottleneck in getting results from the CDPH because they work with so many counties that need Zika testing. Results take between two and four weeks. Dran hopes Zika will soon be dealt with like any other disease or virus by the CDPH: Health centers provide blood tests at local or county clinics and report positive results to the state department of health.

"Zika is not going anywhere for a while," Dran says. "Testing is going to become part of the normal prenatal profile once we can test for immunity, as much as we test for rubella for every pregnant patient."

Kennedy, who is also a board-certified obstetrician, says rural and low-income counties have an especially difficult time delivering blood specimens for testing. She says many rural communities lack county public health labs. A courier takes samples to a lab within 12 hours, and the lab sends them to Sacramento for testing.

Kennedy says health care providers in counties with strained resources refer patients to their county health department for information when asked about Zika.

"This is where disparities become obvious," Kennedy says. "As a physician with a master's in public health, it has taken me hours within each county to figure out each county's system. There's very little chance a really vulnerable patient is going to be able to do this."

Early Prevention and Screening of Underserved Communities

Kennedy gets most of her Zika updates from Jenna Dran at UCSF. Dran's team built a screening questionnaire into their electronic medical record so each patient is prompted with questions about recent family travel. She says it's excellent, but many community clinics lack the resources to create a program like this.

"There are a lot more patients falling through the cracks because most providers don't have a systematic way of screening people," Dran says. "They might not even be using electronic medical records yet."

Dran says early prevention methods include approaching at-risk communities to provide resources for installing window screens and distributing bug repellent and educational information.

"I know that's something they've done in Puerto Rico," Dran says. "A cultural shift has to take place within a community to accept that this is something that needs to be done, which is usually a matter of providing education."

Kennedy says Congressional funding for prevention and screening would allow states to appoint experts exclusively focused on Zika, much like Dran is for UCSF. They could standardize procedures, ensure adequate facilities and help predict demand for future testing.

Training Nurses in Early Prevention and Education

Kennedy plans to implement a Zika screening program for patients of reproductive age at Planned Parenthood Northern California within the next two weeks. It will include questions about a patient's and her family's recent travel history. She says their nurses will also be trained to speak to patients about Zika prevention at home and abroad.

"Our health care system would collapse and patients would suffer if we didn't have our nursing colleagues. Zika is just another example of that." - Sara Kennedy, Planned Parenthood Northern California

Kennedy says other hospitals and clinics should follow suit and train their nurse practitioners. She says nurses across the country will play a crucial role in Zika prevention and awareness in underserved communities because the majority of services at community health clinics are provided by nurses. They're the first to screen patients and the first who can help prevent the spread of Zika.

"Our health care system would collapse and patients would suffer if we didn't have our nursing colleagues," Kennedy says. "And Zika is just another example of that."