Studying the Zika Pandemic from Global and Local Perspectives

On Feb. 15, the Law & Health Care Program (L&HCP) and the University of Maryland, Baltimore Center for Global Education Initiatives held a campuswide symposium during which legal and medical experts from the United States and Costa Rica described the many faces of the emerging Zika virus. The symposium, “Zika Global to Local: Addressing the Epidemic from an International and Interprofessional Lens,” looked at the virus that is moving deeper into North America and how different sectors in the U.S. are mobilizing to stem the spread of the virus and limit its serious side effects. The panelists were L&HCP professors Leslie Meltzer Henry and Michael Greenberger, University of Maryland School of Medicine faculty members Jon Mark Hirshon and Kathleen Neuzil, and the Ambassador from Costa Rica to the United States, the Honorable Roman Macaya Hayes.

The Zika virus hit South and Central America hard in 2016, causing those countries to develop expertise in pandemic response earlier than countries in North America. As Zika moves northward and becomes endemic in U.S. communities, how the United States addresses the virus will be greatly informed by the experience of countries in Latin American where the virus first emerged. To that end, the L&HCP was honored to have Costa Rica's ambassador to the U.S., Dr. Roman Macaya Hayes, open the symposium and share Costa Rica’s experience with the virus. 

The ambassador was a perfect spokesman for Costa Rica’s pandemic response efforts because, in addition to being a diplomat, he is a chemist and biochemist by training and has led R&D teams in the fields of biotechnology and biomedical research in the past. Ambassador Macaya described the country’s immediate and targeted approach to surveillance, detection, and treatment when Zika was first identified in the country. Because Costa Rica has a nearly universal health care system, public health authorities were able to quickly identify and treat individuals who came down with the virus. Those individuals were monitored closely and treated. Education campaigns were initiated early in the emergence of the virus and were particularly directed to pregnant women given the risk of the disease to unborn children and the potential for serious congenital malformations such as microcephaly. Now that the virus has waned, the ambassador reported that only two infants had been born with microcephaly linked to the virus. Participants at the conference were particularly struck by the value of a public health system, a unified medical record system, and responsive communities to quickly address a pandemic illness.

A number of University of Maryland, Baltimore faculty members are using their expertise to develop and refine the legal, medical, and regulatory tools needed to face a new epidemic. Dr. Jon Mark Hirshon, professor in the Department of Emergency Medicine and in the Department of Epidemiology and Public Health at the University of Maryland School of Medicine, described the clinical and epidemiological characteristics of the Zika virus.  Dr. Hirshon recently published “Zika Virus: Critical Information for Emergency Providers” with colleagues and, as a board member of the American College of Emergency Physicians, is working on the organization’s guidelines for the virus. Dr. Hirshon described how, for most people, Zika is not harmful but, as noted above, can cause damage to infants in utero. How Zika will spread through the U.S. is likely to be similar to the spread of West Nile virus, which is in the same flaviviridae family of mosquito-borne arboviruses. He described how the West Nile virus has, in some ways, prepared us to respond to the Zika virus.

Dr. Kathleen Neuzil, director of the Center for Vaccine Development (CVD) at the University of Maryland School of Medicine's Institute for Global Health, explained that CVD was chosen as one of three National Institute for Allergy and Infectious Diseases (NIAID) study sites for a human safety trial of a new Zika vaccine. The early-stage study will evaluate the experimental vaccine's safety and ability to generate an immune system response in participants. Neuzil explained that existing vaccines for other flaviviruses serve as a models for a possible Zika vaccine. Several vaccines are under investigation. Two phase 1 trials of DNA-based vaccines are underway. A phase 1 study of a Zika purified inactivated virion will start soon – this is a vaccine similar to vaccines licensed for the Japanese encephalitis virus. Finally, a live attenuated vaccine (LAV) is under development but not in trials yet. A LAV is currently available for Dengue fever, which is similar to Zika. In sum, there are a number of possible vaccine approaches in the preclinical and clinical study stage, but nothing likely to be available in the next few years. On another note, Neuzil noted that a vaccine designed to treat sexual and intrauterine infection must be safe in children. She explained that the childhood measles-mumps-rubella vaccine ended the 1964-65 U.S. rubella epidemic that, prior to the vaccine, caused 11,000 miscarriages, 2,100 newborn deaths, and 20,000 babies born with congenital rubella syndrome. 

L&HCP Professor Leslie Meltzer Henry, who is on the faculty at UM Carey Law and a core faculty member at the Johns Hopkins Berman Institute of Bioethics, spoke next about the Zika virus and women of reproductive age. In the last several years, Professor Henry has been working intensively as a co-investigator on two projects relating to the ethical conduct of medical research, one called PHASES (Pregnancy & HIV/AIDS: Seeking Equitable Study), which is looking at conducting research about HIV treatment and prevention during pregnancy, and the other, a Wellcome Trust to develop ethical and legal guidance for conducting research with pregnant women during public health emergencies, like the Zika crisis, where there is an urgent need to attend to the health needs of pregnant women and their offspring. 

In her presentation at the Zika symposium, Meltzer compared the advice given by public health officials in Latin America to women of reproductive age versus the lived reality of these women. In particular, many public health officials have recommended delaying pregnancy for long periods of time to avoid exposing unborn children to the virus. However, in Latin America, where 52% of pregnancies are unplanned and access to contraceptives may be limited, delaying pregnancy may not be an option for many women. She also discussed a critical problem in vaccine and clinical research – the reluctance to enroll pregnant women even when the vaccine is generally considered safe or when the most serious side effects of the illness impact pregnant women and their fetuses. Henry argued that additional research is required to determine what research requires participation of pregnant women and what the barriers are to conducting such research in certain target countries. 

Rounding out the discussion, Michael Greenberger, a professor at UM Carey Law and director of the University of Maryland Center for Health and Homeland Security (CHHS), spoke about the law surrounding public health emergencies, particularly disease surveillance, quarantine and isolation. Having served as an expert advisor during prior epidemics (notably Ebola and H1N1), Professor Greenberger shared his conclusion that the most effective way to mobilize American municipalities and citizens during an epidemic is education and leadership rather than the force of law. Whereas Ambassador Macaya stated that, if a safe Zika vaccine become available, it would be required in Costa Rica, Greenberger noted that such an approach would not work in the U.S., where coercion is not the most effective way to mobilize the population.