Zika Virus Update

Experts discuss the Zika virus health emergency, its impact on Brazil, and actions that need to be taken to prevent a crisis.

FINK: Hello, everybody. Thank you very much for joining us for our conference call today. I’d like to remind everybody that today’s Council on Foreign Relations conference call is on the record.

And I’d like to introduce our speakers today: Laurie Garrett, senior fellow for global health at the Council on Foreign Relations and Dr. Claudio Maierovitch, director of the Department of Communicable Disease Surveillance at the Ministry of Health in Brazil.

Just a quick—by way of quick introduction, as of late January the World Health Organization was predicting that up to 4 million people in the Americas could be infected during this season—this mosquito season with the Zika virus. It’s affected some 23 countries and territories so far, with an estimated roughly 4,000 cases of microcephaly that are being investigated in terms of potential link to this virus. Last week, the WHO declared a potential link between microcephaly and other neurological disorders, and Zika virus as a public health emergency of international concern. And they set out a research agenda, a lot of questions that need to be answered.

I am reminded of Dr. Chan—Margaret Chan, the current director-general of the WHO, something she said early in the Ebola outbreak in West Africa, which was something to the order of: An old disease in a new context will bring new surprises. So starting off of that, Laurie Garrett, you’ve covered—you’ve been an expert on many of these infectious outbreaks. Can you give us an overview of what is the history of this disease, and what do we know about it in its new context?

GARRETT: Well, thank you Dr. Fink, not Ms. Fink. (Laughs.) You know, Zika virus is one of those things that’s been around for a long time. Nobody really paid a huge amount of attention to it till fairly recently. It was discovered accidentally in 1947 in Uganda in a yellow fever research effort, and was not then associated or noted to be connected to any human disease. It was seen as an equatorial African virus, that cycled through Aedes africanus, a type of mosquito that was unique to the tropical rainforest zone across from east to west Africa.

The first real human outbreak seen and associated with Zika virus was not until 1968 in Nigeria. And even then, it was fairly small. And the number of cases was fairly small. The basic symptoms noted, some fever, a mild skin rash, joint pain, malaise, and a self-limiting infection that would last only a few days. Some cursory efforts determined that it looked like the incubation time was about five days. Now, we flash forward all the way to 2007 before we see a serious outbreak outside of the African continent. That is on the islands of Micronesia, particularly in the city of Yap. And there it really exploded and has, over the subsequent eight years, spread sequentially across the Pacific island region.

By 2014, was responsible for a fairly large outbreak in French Polynesia. By 2015, had appeared in Easter Island and jumped across Latin America, first noted in Brazil in April or May of last year. And really exploding alongside El Nino conditions and climate conditions that have favored viral—or, shall I say, mosquito breeding in the summer months now in South America, particularly in Brazil, so October to January. In each case, these outbreaks of Zika have been preceded by dengue and chikungunya, and in the case of Brazil, by yellow fever. And exactly why they are preceded by the other also-mosquito carried disease is not known, but may be very important in the end to understanding the actual Zika disease process.

We know that the mosquitos that can carry all three of these diseases exist in the Americas, though they are not native to the Americas. They have been imported over recent decades. In the case of Aedes aegypti, they were hitchhikers on slave ships and go back to the 1600s. We know that the proper mosquitos that can carry all three of these viruses exist in North America, particularly in our southern states. And though now it is winter there and the mosquitos are hibernating, we are very anxious about what will happen when the mosquitos emerge come spring and summer.

What do we know specifically about disease associations and the ongoing Zika investigation? Well, in the case of dengue, we know there’s four subtypes of the virus, and that any one of them by themselves is not terribly dangerous. By in a mechanism that seems to be very complicated, if an individual, particularly a child under five years of age, is exposed to more than two subtypes of dengue they may go into dengue hemorrhagic fever, which is a very, very serious disease. About a half a million people a year get it, and it kills about one out of every five of them, mostly small children.

Chikungunya is less well-understood. And though it is probably just as ancient as dengue, we have not studied it anywhere nearly as much. We do know that it’s of a totally different class of virus, but also carried by the exact same mosquito populations. And we know that it produces a series of symptoms that are very nonspecific—achiness and myalgia, tiredness, flu-like—that can become quite extreme in rare cases. And we know that combined these two viruses have very high attack rates, meaning if a population is exposed to the mosquitos a very high percentage of the population is likely to become infected. In the case of chikungunya, it’s about a 38 to 60 percent attack rate. In the case of dengue, the low is 40 percent, attack rates as high as 90 percent of exposed human beings have been seen.

With Zika, we don’t know what the attack rate is. We don’t know a lot about Zika. Many of the basics that we understand with dengue and chikungunya are not well-understood in the case of Zika. We have no—

FINK: Let’s bring in—

GARRETT: Can I just say one more thing?

FINK: Sorry. Yeah, please.

GARRETT: We have no good test for Zika. We have no test that can discriminate between Zika, dengue, and chikungunya on a routine basis. And finally, just today, Fiocruz, which is sort of the NIH of Brazil, announced that they have demonstrated the possible transmission of Zika through saliva and urine, as well as now three examples of transmission via semen. Over to you.

FINK: That is—sure—that is transmission, or they’ve detected the virus in those fluids?

GARRETT: They’ve detected influence in clusters where transmission occurred. They cannot demonstrate, as is often the case with many things with Zika, a clear chain of events that says cause and effect.

FINK: OK. Thank you very much. That was a great overview. And I also want to just mention, we will go to caller questions in a few minutes, but I would like to bring in Dr. Maierovitch. Dr. Maierovitch, if you could give us, first of all, what seems—is so stunning was that Brazil picks this up, this link—potential link between the microcephaly, the children born with very small heads, potential association between that and Zika. So I’d love to hear just the story of how that was accomplished. And then if you could bring us up to today what is the current status for Zika in Brazil, what kinds of measures are being used to help prevent transmission, prevent any possible of these side effects and these negative effects of the virus. And then finally, just about the research agenda that’s set forward, and where things stand with those three things.

MAIEROVITCH: OK. Good morning. Thank you for inviting us. We are pleasure to be in this conference.

Well, it was new. Even the infectious disease specialists, most of them had never heard about Zika virus. We have dengue virus for over 30 years, and repeated epidemics. Last year we’ve had the major epidemic in the history of Brazil. But we have never heard about Zika. At the beginning of 2015, we began to hear about a symptomatic disease in the states of northeastern part of Brazil. And at the beginning, it was in little cities, little outbreaks of that disease that left in a few days without any complications. We sent our field—(inaudible)—teams there looking for many possible causes, many kinds of virals—retrovirals, enterovirals, and we couldn’t get—(inaudible).

In April 2015, a scientist of the state of Bahia, University of Bahia, he did find the Zika virus for the first time in Brazil. Then our reference laboratories began to look out also for Zika virus, using the same DNA sequence, and identified it in many of the cases in the northeast. At that time we already had together epidemics of dengue. So many cases were positive for dengue, and at that time, we couldn’t separate those. And we thought it was dengue in the multi-exposed population that could have some much similar sickness.

When we were investigating that, we heard of the first cases of the Guillain-Barre syndrome, in the same states where we were having the outbreaks. It was in Bahia—

FINK: And since that’s—for those who don’t know, Guillain-Barre is a neurological disorder that affects not only the babies.

MAIEROVITCH: Yes. It’s a possible disorder that follows. In many infectious disease, it can appear a few days or a few weeks after the actual disease. And when it appears, usually the infection is not present anymore. It can be very severe. It can cause death—(inaudible)—paralysis. And, well, when we began to investigate that, we had heard about some similar cases in the outbreak of Polynesia 2014, and we did have some positive results of tests for Zika virus by PCR. It’s a molecular method to identify genetic materials of the virus, and it went on. So we calculate we must have had about 2,000 extra cases of Guillain-Barre in our public system in the range of 2015.

When our teams were still in the field investigating Guillain-Barre, we heard about the first cases of microcephaly from the state of Pernambuco, where usually—where we used to have 10 to 12 cases a year of microcephaly. It’s a malformation in which children are born with underdevelopment of the brain. It’s a real severe situation, and we had never heard of outbreaks of this kind. The scientists had never heard of this and it was not described before. In the investigations of these cases, many of the mothers are told they had had some symptoms that looked like Zika virus infections in the beginning of their pregnancy. The cases multiplied. They grew with exponential proportion in the months of October and November, and began to appear in the other states of northeast.

When we looked at the registers, we saw the growth of the cases began in August, then maintained in September, and really exploded in October. Some aspects made us think about the link between the two situations. First, the before the increase, in the same year you have had some six to seven more before the outbreaks of Zika virus. We must have had in Brazil thousands of—hundreds of thousands of cases of Zika virus infections in the northeastern part of the country.

Also, we observed the epidemiological pattern of microcephaly was not typical of other kinds of diseases that are transmitted by other ways. It should not be the environment-caused disease. It should have an epicenter and cases around it. Also, it was not certainly a sickness transmitted from person to person, because it appeared at the same time in all the regions of the state of Pernambuco. It’s a big state of Brazil. It looked like a vector-borne disease, transmitted by an already-existing vector. That was our hypothesis—OK.

FINK: Sorry. Please go ahead. Yeah, sorry.

MAIEROVITCH: Yeah, OK.

FINK: I thought it might be good to maybe—and where are you now in terms of the situation? And what are you trying to do to stop the spread at this point, and where does the research lie?

MAIEROVITCH: OK. Just to close this part of the relation between that, it’s part of our research, we’ve had typical images by ultrasound and (computed ?) tomography of the children, looking at a pattern similar to many infectious diseases, congenital disease that are cause this malformation. Also, we began to have some positive results of children. Most children died minutes after birth, and also from stillbirth and miscarriage. There were what we called the—(inaudible)—identification of Zika virus, by PCR also.

From that, we began to—(inaudible)—designing a—(inaudible)—cultural study, also a couple of studies—(inaudible)—we asked for the help of the PAHO, Pan-American Health Organization, but also called the mechanism of—(inaudible)—with a global mechanism of cooperation that sent their specialists from CDC of Atlanta participating in collaboration with us in the design of these studies. In November last year, they declared a public health emergency of national concern in Brazil, and suggested that the WHO study the same because the current risk of disease that was it would spread for all the continent.

Now we are working in many fields. The main task for us to reduce the mosquito—the mosquitoes infestation all around Brazil. We have every state involved. We have all government involved in not only health, but including our president is involved in calling the country to fight against mosquitos. And we have some studies—epidemiological studies looking for more evidence linking Zika virus and microcephaly. We have current studies following pregnant women that presents—(inaudible)—at our health services. And we already began to look for corporations to developing new technologies for diagnosis and also for the development of a vaccine specific for Zika virus.

As was told before, we have trouble in diagnosis because, well, we don’t have even yellow fever for more than 50 years in Brazil. But we do have dengue, and we have Chikungunya, and some other arbovirus in the forests in Brazil. And we have some possibility of false-positive exams when we use (pharmacological ?) tests.

So we have been using molecular tests, and they are tests that identify the virus during the acute infection, only when people have the symptoms. So we can’t recover cases that have the—(inaudible)—like we imagine it must have happened with the mothers of the children with microcephaly.

Our laboratories have developed some new methods, including—(inaudible)—that was mentioned, to have new methods for diagnosis.

FINK: Thank you. Thank you very much for that overview. Was there something else you wanted to say? Otherwise I would like to open the question-and-answer session.

MAIEROVITCH: Well, OK. I think you can open.

FINK: OK. So at this time I would like to invite members to join our conversation with their questions. A reminder: This conference call is on the record. Please limit yourself to one question and keep it concise to allow as many members as possible to speak.

Do we already have any questioners in the queue?

OPERATOR: We do. We have—our first question is from Karen McClendon from Simpson Thacher & Bartlett.

Q: Thank you.

So this has been very helpful and informative. And I think one of the questions I have is whether the risk of microcephaly is only present if an individual is infected while pregnant. In the case—and I’m not sure if there have been any—of a woman who might be infected with the Zika virus but doesn’t actually become pregnant until six months or a year out, is there still a risk that her child would be at risk for microcephaly?

GARRETT: Well, Sheri, I’ll take that.

First of all, we have not 100 percent proven if and how Zika causes microcephaly. So, you know, you’re asking ahead of where the science is right now. But the assumption is that it is a process that occurs during the first or second trimester of pregnancy that affects the skull development of these babies.

Q: I see.

FINK: OK. And, Dr. Maierovitch, did you want to add to that or shall we go to the next question?

MAIEROVITCH: Well, I think it’s clear with what we have been observing here that pregnant women must have got infection the first trimester of 2015, around March or April, and then the first cases of microcephaly were observed in September-October. From what we know now, the infection must be present about two weeks. And so we think the danger is for pregnant woman that acquire the virus while they’re already pregnant, and probably the risk is greatest in the first months—the first three months.

FINK: Thanks. And I think that also fits with what we’ve been told about why we wouldn’t have or why the world wouldn’t have seen a lot of microcephaly cases where Zika has been for a long time, the idea being that people who have had the virus when they’re young then wouldn’t be susceptible at the time that they were pregnant, presumably.

Let’s go on to the next question.

OPERATOR: OK.

(Gives queueing instructions.)

Our next question comes from Kellie Meiman with McLarty Associates.

Q: Great. Thank you very much to all the participants.

I was hoping that we might hear a little bit more about the education efforts that are currently under way in Brazil with regards to prevention and how you see that as part of the at least interim solution. Thank you.

FINK: Dr. Maierovitch.

MAIEROVITCH: Thank you. Well, we’re leading a big national effort to fight against the mosquito, because we think it’s the only thing that can be done right now to prevent new outbreaks of microcephaly. It involves the areas of health care, and also education, civil defense, and also the army. All government areas are involved in this effort.

We have also public campaigns telling people about the risks and telling people how to prevent from the multiplying of the mosquitoes, from breeding the mosquitoes, eliminating all possible things that can collect clean water. And they’re all around. So we’re trying to multiply our information and our communication with people, especially when we think about hot spots of risks where we are used to have the huge epidemics of dengue.

GARRETT: I would just add, Sheri, that the messaging across the region outside of Brazil is very different and inconsistent. There’s—you know, one can hope that we’ll begin to see more consistent messaging. But, for example, El Salvador’s government has basically responded to the threat by telling all the women of El Salvador not to have babies until the year 2018. In Colombia, the response has been very localized to a few key states, and there they’ve put most of their resources and attention. And they say they don’t see a microcephaly link. Of course, it is newer there. And the women—many of the women who were exposed in first trimester have still not given birth.

And as you move your way up into the Caribbean, you can see a very diverse set of messages and public-health education. I think that’s even going to become more the case once it shows up in the United States and we have our mosquito populations coming out of hibernation.

Q: And do you want to talk, just as long as we’re on this subject of what other countries are doing—Brazil, it’s a very robust response; obviously also detected this. But what about Venezuela? What about neighboring countries? What is the capacity to respond in those places? Are there some cross-border kind of cooperation happening? Or is that lacking right now?

GARRETT: Well, I could start on that and Claudio can add from his perspective in Brazil. But we—again, we have a mosaic of responses. Venezuela was very slow to acknowledge that they had any Zika at all, and then suddenly announced they had more than 4,000 cases. We—you know, there are very great differences across the region in the local economies and in their capacity to respond.

So, Venezuela being an oil-dependent economy that was in a tough position even before oil prices plummeted, has real resource problems, real scarcity of supplies for response. And, you know, we—I think Claudio can tell you that there was just a big meeting yesterday in Montevideo of regional responders. Claudio, what was that? Can you fill people in on that meeting?

MAIEROVITCH: Yes. Last week there was a meeting between the presidents of countries of Mercosul, and our president told them about the emergency situation in Brazil, and called a meeting between ministers of health of Mercosul and associated countries. It was held in Montevideo the day before yesterday. There, our countries committed to a big priority to combat the mosquito, and also to make information clear and quick between the countries, and with our international avenues. In our case, PAHO is the main actor in this—in this situation. It looks to us that the other countries of South America are in the beginning of their own histories. We, in Brazil, verified the presence of Zika virus in April. And it looks like they are seeing now the first cases of Zika infections. So it must take some months until they see the more severe consequences.

We’re trying to get cooperation effort between the countries of South America, Latin America, and also countries that can collaborate with us in all the Americas and all over the world. We already have signed a memorandum of understanding with CDC, and it’s on just some work about laboratory cooperation and also epidemiological studies.

But we are afraid the speed of spreading of Zika virus will be really great. When we talk about—when we think about what happened with Chikungunya some two years ago, that it got to Central America and the Caribbean region at the end of 2013. And in a few months, we’ve had a million cases of Chikungunya in the region. In Brazil, it was not so fast. So when we see how fast was Zika virus in Brazil, we really should be afraid. We really should have a concern on what will happen when Zika virus really spreads throughout the region.

FINK: Thank you.

Let’s go to the next question, please, from our members.

OPERATOR: Our next question comes from Eileen Johnson (sp) with Comosa Incorporation (sp).

Q: Thank you very much. And thank you for this informative session. I’ve read several articles or reports that have noted the incidents of Zika and microcephaly correlate closely with areas where there had been attempts to control mosquitos through genetic modification. Now, obviously this is correlation and not causality, but I wonder if either of our speakers has seen these articles and whether or not among the many activities that the Brazil authorities are involved in there includes an exploration of the possible link between genetic manipulation of mosquitos and a subsequent emergence of what appears to be a much more dangerous strain of Zika.

GARRETT: Well, I’ll just say two things and then I’ll hand it off to Claudio. There is no evidence that genetically the Zika strain is different in any significant way from the form of Zika virus that has been circulating in the Pacific islands. So there has been no change in the virus itself. As for the association with genetic modified—genetically modified mosquitos that, you know, this immediately was raised as a possible cause, along with all sort of other allegations related to environmental factors, use of chemicals, and so on. I would just note that it would not in any way explain the outbreaks across the Pacific island regions, because they did not use genetically modified mosquitos as elements of their mosquito abatement programs in those regions.

Claudio?

MAIEROVITCH: Yes. First of all, it’s a big thing to recall. They left to—we began to link the two things. Some scientists of Polynesia looked back and found some 17 cases of microcephaly at the same time the had—just a few months after they had the outbreaks there, making also the possible link. There are genetically modified mosquitos in some subject of research in Brazil in very isolated areas, in only two cities in Brazil, called Juazerio and Jacobina, in the state of Bahia. We know the genetically modified mosquitos lives a few days, and then die. They are not well-adapted to the environment. We’ve all the evaluation by environment agencies in Brazil before any research was authorized. And also, I confirmed that many scientists in Brazil have sequenced the Zika virus that is circulating now, and it’s the same Zika virus—the sequence is quite the same—that came from Asia.

FINK: OK, thank you. Next question, please, from our members.

OPERATOR: (Gives queuing instructions.)

Our next question comes from Joy DiBenedetto from Human Unlimited Media.

Q: Yes. Hello. I appreciate so much that you’re doing this conference call today. My question actually refers to the transmission aspects of the virus. Dengue, yellow fever, and now Zika all appear to be spread by the same mosquito, but Zika seems to have a different transmission function, even though it’s still spread by the Aedes aegypti. And I wonder if you can talk about the difficulty of trying to treat Zika with now the cases that are coming to light of possible sexual transmission, as well as Zika virus being found in urine and other bodily fluids. And how difficult does that make the mosquito issue for you, and also in treating the Zika virus, and perhaps the other viruses associated with this mosquito?

GARRETT: OK, I’m going to take this apart a little bit, just for the sake of clarity. There is no treatment, per se, for Zika, regardless of how you get it. And there’s no particular connection between the disease course and the mode of transmission. So let’s put the treatment over to the side and focus on the transmission question.

By far, the majority of all transmissions are associated with the Aedes aegypti mosquito. But there are these rare cases—we think rare, needs much more research—of sexual transmission and now the revelation that Zika can be isolated from urine and saliva. What I think is the most important thing to focus on going forward is what this will mean when Zika—when our mosquitos emerge in North America. Will we see Zika confined to the same mosquito populations, Aedes aegypti? We have Aedes aegypti across more than half of the United States. Or, will it expand to include Aedes albopictus, which we also have? Or will it take a turn, such as we saw with West Nile virus in 1999, which arrived from Africa, we still don’t know how, and showed up in the concrete jungle of Queens New York, and spread from there so that now it’s endemic. It arrives every single year now. It is across most of the United States. And it affects more than 60 different mosquito species and a broad range of birds, horses, and homo sapiens, such that it’s hard to find crows anymore in North America or song birds, because they’ve been devastated by the West Nile Virus. We don’t know what Zika will do and the mosquito populations will do, when it hits the North American ecology.

And now I’d hand off to you, Claudio, on this question of modes of transmission.

FINK: Before we do that, I just want to clarify. There have been reports in the literature of Zika being isolated from the urine and from the blood serum. And just looking back, I did a quick literature search while you were speaking. So this is not the first time. And I want to just make sure our listeners know that there is no—as yet, no evidence, at least that I see here and from the initial reports today—that it can necessarily be transmitted through the mechanisms. So I just don’t want anybody—you know, this is definitely something that is needing to be followed-up by research, but let’s just make sure not to necessarily leap to—we certainly don’t know at this point whether that would be a mode of transmission, through body fluids as opposed to primarily through the mosquito vector or through—

GARRETT: But our blood banks are—our blood banks are trying to discourage donors who have traveled in Zika areas. And we don’t have a good quick screening test for the blood supply.

FINK: Thank you.

GARRETT: Claudio.

MAIEROVITCH: I think that many of the virals are still a mystery.

FINK: Claudio, are you still with us? We’re having trouble hearing you. I think we may have lost him. Let’s go to the next question and see if we can get him back.

OPERATOR: Our next question comes from Kenneth Oye with MIT.

Q: This is Ken. I’d also like to thank Dr. Maierovitch for, again, the excellent briefing on these issues. A quick comment and a question. The comment is that I agree completely that it is basically impossible that the Oxitec experiment could have led to or created the problem with Zika virus. Zika is an—(inaudible)—flavivirus and it’s impossible that the modifications that were made to the Oxitec mosquitos could have produced and adjustment or a change. And Laurie, as you pointed out, there’s continuity, it’s the same as what has appeared in other part of the world.

The question that I have follows up, Laurie, on your comment that we need to know a lot more about whether other mosquitos could serve as a vector, looking to possible movement north. The question here is, do you know who is doing the research on that issue? Are people working on that now? It’d be kind of nice to know ahead of time.

GARRETT: Yeah. Thanks for that. Fiocruz has done a number of experiments in their laboratory setting in Brazil and shown they can infect Culex mosquitos. And of course, West Nile Virus was able to really take off in North America thanks to Culex pipiens, though eventually, as I said, it went to 59 other mosquito species. I mean, there’s a very obviously aggressive effort going on both at—in Galveston at the University of Texas medical branch, and at the CDC, trying to figure out what kinds of mosquitos can be infected.

Now, demonstrating that a given mosquito can take up the virus into its proboscis and then inject the virus into a test animal is only step one. That doesn’t tell you what will happen in the natural ecology when mosquitos are competing against other mosquitos and they’re in the natural environment. And unfortunately, we probably won’t really know the answer to that until this spring when we see what happens in North America.

Q: I was afraid that that was going to be your answer, Laurie. Thank you very much.

GARRETT: Sorry! (Laughs.)

FINK: OK. And do we have Dr. Maierovitch—

MAIEROVITCH: I’m back. I came back here, OK.

FINK: OK. Would you like to finish your answer to the previous question, or add anything to this one?

MAIEROVITCH: Sure, thank you. Sorry for the missing minute. As I was saying, we found the West Nile Virus for the first time about 20 years ago in Brazil. We looked out, and we didn’t find anything else about this, although it had several mosquitos that could transmit it. So we don’t understand yet completely the relationship between many mosquitos and environment, especially when we see complex situations like our cities today, like the amount of garbage that humans generate today, and the favorable environment we are building for mosquitos. We have heard about the presence of the virus, like the Zika virus, in blood. And, you’re right, for many years it was already known. What we have new is that it was identified in semen, and not only identified, but the researchers verified they could multiply the virus identified in semen, and also in saliva.

For now, it doesn’t look for us it would modify the course of the epidemics. The power of transmission by mosquito is far superior to the possibility of sexual transmission or other ways of transmission. We are beginning to become worried about donor blood, donor transmission, especially because we don’t have yet a good test to be—to be done in huge numbers of donations. But I think it’s only a question of time. We’ve already identified one case of blood transmission of Zika virus in Brazil, in the state of San Paulo, in the beginning of our epidemics.

FINK: Thank you.

GARRETT: I would just one last thought on that point. You know, once we have transmission in the United States, and we start to see the mosquito populations in the southern states, all these issues that are we discussing calmly right now on this conference call, especially questions—oh, is it in the urine, oh, is it in blood, oh, is it semen and so on—will take on an almost hysterical tone in America. Unfortunately, that’s how the American population responds. We saw it with Ebola. Almost no particular interest until the Dallas case and transmission from one Liberian patient to two nurses in Dallas. And suddenly Twitter went wild, Facebook went wild, media coverage went crazy.

And what I would urge—since we have so many prestigious individuals from around America on this call right now—I would urge you to try to consider what kinds of advanced policies your companies can take and your institutions can take to educate your employees and to educate the higher tiers of your corporation structure so that at least your institutions do not respond in a hysterical way when Zika turns up in North America, and we’re able to take a rational, smart response. God help us if we end up with a response that gets mixed up with our presidential elections. Let’s keep this on as smart a tone as possible. And North America should learn from South America. We should pay close attention to the lessons being derived from Brazil and learn, so that we respond at least as wisely as the Brazilians have.

FINK: Thank you, Laurie.

We have about 60 seconds left. Dr. Maierovitch, would you like to leave us with any parting thoughts?

MAIEROVITCH: I think we should think in Zika virus as another neglected disease that came to us. I believe—really believe that we can get collaborative initiatives like we already have, promoted by the WHO, to get some rapid responses, rapid answers, to build more knowledge about Zika virus, microcephaly, and other possible consequences. As the government of Brazil, we’re open to every kind of cooperation that gets us closer to responses.

FINK: I would like to thank Senior Fellow Laurie Garrett at the Council on Foreign Relations—Senior Fellow for Global Health Laurie Garrett, as well as Dr. Claudio Maierovitch, director of the Department of Communicable Disease Surveillance for the Brazilian Ministry of Health. Thank you so much, both of you, for helping us understand this developing situation. And thanks to everyone on the call, and to our—the people who asked questions to our members. Thank you very much also to the—our excellent operator for this call. Thank you so much.

GARRETT: Thank you.

MAIEROVITCH: Thank you for the pleasure to participate.

(END)