natural treatment for smallpox disease traditional

>>susan perkins:hi, everybody. welcome to this very special edition of scicafecalled zika: what you need to know. my name is susan perkins, and i'm the curatorof microbial genomics here at the museum. and i'm going to be moderating tonight's panel. i'm also the curator of our current exhibitthat's going on called the secret world inside you, which is all about your microbiome. and if you haven't seen it, don't delay becausethe show will close in mid-august and move on. so, tonight we're thrilled to have three scientistsjoining us this evening to talk about the

latest news on the zika virus outbreak andanswer questions. so, i'm going to begin by asking a seriesof questions that are general about the virus, its transmission and the risks, and then we'llopen up the floor to your questions. and as always, we encourage you to tweet anduse the hashtag amnhscicafe. and, finally, before i introduce our panelistsi want to thank the science education partnership award or sepa program of the national institutesof health for their generous support of tonight's program. our first panelist is dr. ian lipkin. he is the john snow professor and directorof the center for infection and immunity at

columbia university. he is world renown for his methods of viraldiscoveries in epidemiology of pathogenic research. ian, please come up to the stage and tellus about your research for a couple minutes. >>ian lipkin:people who come to visit us say that their visit's like an episode of csi microbiology. so, what we do is we discover bacteria viruses,and we try to figure out their roles in health and disease. and you've already talked about the - i guess,the exhibit that you now have, which is closing

in august. we have some footage in that particular exhibit. it was a lot of fun to help participate inthat exhibit. i was brought here to new york in 1999 shortlyafter our group discovered west nile virus here. at that point, i was in california. that's the last mosquito-borne outbreak thatwas severe that hit the new york city area. so, in addition to studying viruses that causediseases that you would recognize as being due to infection like pneumonia or hemorrhagicfevers or diarrhea or skin infections that

you can readily see, we also study the roleof viruses in autism and cancer and diabetes, a whole range of interesting conditions thatyou wouldn't think of as necessarily being due to infection. >>susan perkins:great. thank you. our next panelist is dr. catherine spong. she's the acting director of the eunice kennedyshriver national institute of child health and human development at the national institutesof health. and she's an expert on maternal and fetalhealth.

cathy, please tell us a little bit more aboutthe work that you do. >>catherine spong:thank you so much. so, the national institutes of health supportsresearch that includes the whole gamut, from basic science through translational researchthrough clinical research. specific to zika virus, we've just recentlylaunched a large multi-country cohort study to follow 10,000 women beginning early inpregnancy and monitoring them throughout pregnancy those who symptomatically get zika, thosewithout symptoms who get zika and those who do not get zika. and we'll be following them through theirpregnancies and the women for at least six

weeks, and the children for at least a year,to try to understand best what is the risk of zika in pregnancy and how can we counselwomen and their families. i'm also - as you mentioned - an obstetrician-gynecologist. i do see patients in washington d.c. at inovaalexandria hospital. and i do get patients who have traveled ortheir families have traveled to brazil and have lots of questions. so, i look forward to the discussion today. >>susan perkins:yeah, we'll hear more about that soon. yeah.

and, finally, is dr. jay varma. he's the deputy commissioner for disease controlat the new york city department of health and mental hygiene. and prior to joining us here in new york,he was with the centers for disease control and had posed in both china and thailand. jay, would you please share a summary of yourcurrent work? >>jay varma:great. thank you, susan. so, as susan mentioned most of my career hasactually been spent working overseas for the

u.s. government working on emerging infectiousdiseases in asia. and i moved to new york city a little overfive years ago to take my current position where i oversee all of the infectious diseaseprograms at the new york city health department. so, one of the things that's great about newyork city is that because we are a global city, everything that happens around the worldhas a potential impact here. so, i've had a great experience to work onnot just diseases that are already endemic here in new york city and of big importancelike hiv, sexually transmitted diseases and vaccine preventable diseases, but also whenwe have emerging epidemics like zika i am the lead for the health department to marshalour response.

and some of that includes helping to get informationout. some of it includes helping to get tests available. and a lot of it really is about coordinationand trying to make sure that every part of the city has a role in trying to prevent andcontrol these infections. and we'll ask you some more details of thatsoon. so, ian, i'd like you to take on this firstquestion, which is really the most basic one. what is zika virus? where did it come from? >>ian lipkin:well, first of all, what is a virus?

>>susan perkins:yeah, let's start there. >>ian lipkin:a virus is a piece of genetic material that's wrapped up in a coat of protein. it may have another shell in addition to that. and it has differences from bacteria thatwe can treat with antibiotics that may not be familiar to many of you. viruses can really only reproduce themselvesinside of cells. so, what they do is once they enter your body,they latch on to cells where they have the capacity to grow, entering through somethingwhich sits on the surface of a cell that's

known as a receptor. and if it finds that receptor, it assumes- if you can attribute intelligence to the virus - that this is a place where it's goingto be able to reproduce itself. once inside that cell, it reproduces itselfthousands and thousands of times, breaks the cell apart and releases many, many more particles. so, it's not truly alive, but it certainlydoes a lot of damage as though it were alive. now, one of the questions that people frequentlyask is whether or not all viruses are bad. and the answer to that is no. there's some that are quite useful, but idon't have time to go into that.

you can ask later if you wish. >>susan perkins:so, what about zika virus? what is it? what's it related to? and can you tell us a little bit about thehistory of it? >>ian lipkin:oh, i'm sorry. you want to know about the zika virus specifically. so, zika virus is what's known as a flavivirus,which is a descriptive term. it's related to west nile virus and denguevirus.

and these are viruses that are typically mosquito-borne,which means that they're transmitted when a mosquito bites you and you're infected oran animal's infected. it takes that blood meal, it flies to anotherhuman or animal, and then transmits that infection. it's called zika virus because it was isolatedfirst in the zika forest in uganda. and it was fairly quiet, and then in the late1940s it began to appear sporadically around the world. we became aware of the first real outbreaksin micronesia in an island known as yap, which is a very, very small island not too far fromguam where the majority of people who are on the island actually became infected.

and thereafter it began to spread. and, ultimately as you've seen now, it's inthe caribbean and in south america. now, there are many cases as well in africa. i mention it's related to dengue virus. this is extremely important because the areaswhere dengue virus is found we're also now beginning to find zika. and i mentioned to you the ways in which virusesenter cells, find a receptor, latch on, enter and begin to reproduce themselves. well, if you've been previously exposed toa related virus like dengue, you may have

what's known as a cross-reactive immunologicalresponse. what this means is that an antibody will bindto the zika virus particle, and the antibody itself, which has a little tag that sticksout of the end, which is called fc for the aficionados, will bind to other cells justthrough that fc receptor. it can actually accelerate the rate at whichthis virus can replicate inside your bodies. so, when we talk about vaccines later on,we'll have to talk about cross-reactivity and the importance of thinking about thatin vaccine design. >>susan perkins:definitely. all right, i want to skip over to jay fora minute and have him tell us a little bit

about the main mode of transmission that weknow about. and we'll talk about other modes of transmissionshortly, but the main mode of transmission is - as ian just mentioned - by mosquito bites,primarily of the aedes aegypti mosquito. jay, can you tell us a little bit about thehistory of the mosquitoes? are they here in the new york city area? is this the same kind of mosquito that transmitswest nile? >>jay varma:so, i think to understand a little bit - to understand the differences between the virusesand the mosquitoes that carry them, you need to know that there are thousands of differenttypes of mosquitoes.

there's probably over 3,000 different typesof mosquitoes that can be found anywhere in and just like humans, they behave differentlydepending on where they are. in the united states, there're probably afew hundred different types of mosquitoes. and, again, some of them - the only harm theymay cause is to annoy you, but some of them can actually have a virus in them that canthen be transmitted from one human to another human. so, as ian mentioned before, the last bigmosquito-borne outbreak that we had in the united states that was worrisome was in 1999,and that was here in new york city where we had the west nile virus.

the mosquito that transmits that virus isknown as the culex mosquito. and just so you understand what happens whenthere is a human that has the infection in them and the virus is circulating in theirblood and the mosquito bites, it is taking a very, very small amount of blood into itsmouth, and then into its gut. and some of these 3,000 mosquitoes in theworld have the ability after they take that blood to have the virus go not just throughits gut, but back through its circulatory system and go back into its saliva, so thatwhen it bites another human - somebody who's never been infected - it can transmit thatinfection. the mosquitoes that transmit west nile virusbehave differently, however, than the aedes

type of mosquitoes. here in new york city, that horrifying mosquitoyou see over there, the aedes aegypti mosquito, doesn't actually live in our climates. it really likes warm, tropical climates. so, it does exist in parts of the united stateslike texas and florida that have that type of climate, but it doesn't really extend thisfar north. now, that may change over time. as we know, our climate is changing, and thatcould change for the future. what's concerning for us is that there isa relative of that mosquito - of the aedes

aegypti mosquito called aedes albopictus. that mosquito is here in new york city. and as we'll talk about, i think, at the end,even though the risk of transmission is probably low with this mosquito - it's not quite asefficient or effective at transmitting infection - it is something that we need to be on thewatch for and control for. >>susan perkins:great, thanks. so, cathy, without a doubt the thing that'sreally capturing a lot of attention and causing a sense of panic in many people with respectto this current outbreak of zika are these frightening developmental complications whenpregnant women get infected.

and so would you please tell us what do wecurrently know about the lengths between zika virus and birth defects like microcephalyand other neurological and developmental problems? >>catherine spong:right. the reason why this has become a public healthemergency really is because of the complications for women who are pregnant and the complicationsfor the fetus. we've seen in brazil really came to lightthese complications of microcephaly where the baby's head is very small. and as we've been learning more about this,we've realized that in fact it's much more than just microcephaly itself.

the impact of having zika during pregnancyaffects many aspects of the fetus. and part of this includes - much of what weknow right now is really just when a women is symptomatic with zika virus infection. and many of the studies that are out therehave looked at symptomatic women and found that there are higher risks of fetal lossor still birth or miscarriage, fetal growth abnormalities where the baby's small, thesebrain abnormalities, the microcephaly, the ventriculomegoly where the ventricles insideof the baby's brain are enlarged, calcifications inside the baby's brain, as well as abnormalstructures or loss of structures within the brain itself.

and then there are other complications aswell: neurodevelopmental complications, motor complications and neurobehavioral complications,as well as eye lesions. much of what we know for the child reallyhas been, again, looking only at the babies with microcephaly and following those children. but in fact we really need to study all childrenwho are exposed to zika virus during pregnancy. and there have been some case reports comingout showing that in fact even children who don't have microcephaly have complications. and i think it's going to take some time forus to really understand the long-term implications of this.

it's not something you can just determineat birth. we really need to take the time to followthese children and see what happens in the long term. we know that when someone is pregnant andgets a viral infection, there can be complications that can be long term. even something as simple as influenza duringpregnancy can result in higher rates of autism or schizophrenia later in life. so, there's a lot for us to learn. in addition, not only to understanding whathappens for these children with or without

microcephaly or small heads, but also lookingat the women who are symptomatic, which is about 20 percent of people who get zika virusduring - zika virus at all have some type of symptom, which is a pretty mild symptom;maybe a headache, a fever, a rash. but about 80 percent of people don't evenknow that they have zika. and it's really important for us to be ableto do studies to capture all of that. >>susan perkins:yeah. wow, it's very sobering. and speaking of sobering, one of the thingsthat has made zika a little different from some of the other arboviruses like dengueand west nile is this evidence that the virus

can also be transmitted sexually between twopeople. and so, ian, would you tell us a little bitabout how this second mode of transmission, in addition to the traditional or typicalmosquito-borne transmission, how is this effecting the epidemiology of the disease? >>ian lipkin:well, i think as jay as said, the major route of transmission is still the mosquito. but recently we've learned that there area wide range of viral infections that can be transmitted via the sex route. a year ago we were concerned about ebola,and what we've learned, for example, is some

viruses have the capacity to lurk in seminalsecretions for weeks, maybe even months. we don't really know yet the full extent ofthat period of time. but what it does mean is that it's not enoughto tell a woman that you need to avoid going to an area where you may become infected,but if you have a partner who travels to this area, we need to make certain that individualis not carrying a virus home, so that you can become infected secondarily. now, there are tests that can be used to examinewhether or not semen has this virus in it. you can do this by culture. you can use genetic tests, and i'm sure thatthese are things that we'll be hearing much

more about. in addition, there's going to be a concern,of course, that it's going to be in the blood supply. and with west nile virus, we didn't reallyworry about that for a couple of years. and then suddenly there were cases that wereassociated with blood transfusion, organ donation. and i would anticipate that this is somethingthat people may become concerned about as well. so, jay, would you follow up on that in amore specific sense? so, how does the sexual transmission complicatethe city's ability to control zika?

and then maybe continue on from there andtell us about what's the potential for local infection from people who have traveled away,whether by other mosquitoes or by person-to-person transmission? >>jay varma:good, yeah. so, i just wanted to add on to what ian justmentioned. i think one of the most important messageswe're trying to get to new yorkers is the importance of understanding your risk of gettinginfected. if you are a woman of reproductive age thatis planning to travel to mexico, central america, the caribbean, you need to be using a durableform of birth control and you need to be using

condoms when you're there. the risk is real. transmission probably does not occur veryoften. again, mosquitoes are the way you get epidemicsof this, but we know that the consequences of infection can be very severe. so, we are advising any woman of reproductiveage to be very careful about durable forms of birth control and the use of condoms. and even more important, if you are a womanthat's pregnant, you really shouldn't be going south this time of the year.

you really should be considering a vacationsomewhere else until the epidemic is changed. and so how it's directly impacting new yorkis, again, the transmission that occurs via the sexual route is probably not very common. again, if the hundreds of cases that havebeen diagnosed in the united states that have been imported, only a handful have been throughsexual transmission. the remainder - the vast majority are allthrough mosquitoes. but the concern is that the way you get thisinfection in a community is you have humans that have this virus in their blood, and thenyou have a group of mosquitoes that are affective at biting those humans and having that infectionspread to their saliva, and then transmitting

it. so, for us the concern is about, one, makingsure new yorkers get all of these messages, which are complicated about all the differentways you could get infected, all the ways you can prevent yourself. and, secondarily, there is always the concernthat this could increase the total number of people with this virus in their blood and,therefore, in the presence of the right mosquitoes you could get transmission here in new yorkor some other setting. and, cathy, i was hoping you could followup with some more specifics. so, jay talked about these general travelersadvice.

but maybe more specifically how does one knowthey have it? you mentioned many people don't have symptoms. how do you get tested? what are the questions you need to ask? any other advice that you might give for peopletraveling to these countries, and then specifically men and women who might be involved in makingfamily choices in the near future? so, for a woman who's pregnant or who's interestedin becoming pregnant or a family unit who's interested in becoming pregnant or is pregnant,i think the first message is not to travel to some place where there is active zika transmission.

and if you are going to travel there, understandingwhat those risks are to take the precautions that you need in order to try to minimizeyour risk of getting zika. so, this is a mosquito that bites during theday, so it's not one that you can say, okay, well, it's during the day. i'm not so worried about it. so, other things that you should do are toencourage people to be in air-conditioned places, to be in places where there are screens,to use repellants that are approved, to wear long sleeves and long pants to try to avoidthat type of transmission. now, for someone who is perhaps not traveling,but they have a partner who is traveling to

a place where there is active zika transmission,again, because of the risk of sexual transmission there is a concern. and so as an example i had a patient in myclinic who she had come back from brazil. she was pregnant. and this was right at the beginning. this was the day actually that the who declaredit a public health emergency. so, it's february 1. it's the last patient of the day, and shecomes in and she's there for an anatomy scan - just a regular scan - and handwritten onthe front of the note was traveled to brazil

over the holidays. is interested in what her risks are. and so they're very concerned. they've heard about this. the who just declared this an emergency. what are the risks to me, and then what shouldi do? how do i protect myself? and our discussion went along the lines ofprobably to avoid going back to brazil unless she really needed to.

and she was comfortable with that and said,"i'm not planning on going back. i understand there's that risk." and then we talked a little bit more, andat that point there'd only been one case of sexual transmission. and i said your partner probably doesn't wantto travel either, or if they do travel you will need to take precautions if you wantto try to avoid that route of transmission. so, either abstinence or using condoms orsome other methods, so as to avoid that risk of sexual transmission. and i think these are things that we needto talk with our patients about.

if someone has - if a male has had zika virusthey should - because of the risk of it staying in the semen for a prolonged period of time- in fact, there was a case report published where a man had active zika and 41 days latertransmitted it sexually to his partner. so, there is that concern. and the recommendation then is to wait sixmonths before having unprotected intercourse to try to prevent sexual transmission in orderto try to capture as much duration as we can. for women or men who travel some place wherethere is active transmission and they are not pregnant, but are thinking about becomingpregnant, the recommendation is for them to wait eight weeks after coming back beforetrying to become pregnant.

>>susan perkins:and what kinds of questions - like this woman that you mentioned and others, i mean, thisis one of the more common things i've heard, is people have gone on a honeymoon to thecaribbean or maybe to brazil, and then they find out they're pregnant and so they're worriedabout the length of time. how are we training doctors to monitor thesethings? and what should they be asking their doctorto test for or look for? so, if someone has come back and they arepregnant and they were at a place where they had active zika transmission, she should betested for zika virus. and there's a whole system out there for howthat is done.

if she tests back positive, she's going toneed to be followed throughout her pregnancy to determine whether or not there are anysequela for the fetus. so, this will require serial ultrasounds andmonitoring throughout the pregnancy. >>susan perkins:but if she tests negative, can she relax? >>catherine spong:so, part of the difficulty - and i know we're going to talk a little bit about this diagnosticsand the cross-reactivity is, as ian mentioned, with dengue. and so the difficulty is that if she has comefrom somewhere where she could have had dengue as well, it's difficult to know for certainwhether or not they had zika or dengue.

if she's never had dengue virus, then youcan feel more comfortable that in fact she has not been infected with zika. >>susan perkins:okay, thank you. so, ian, in the last couple days there weresome splash in the news about maybe we're on the hot trail of some vaccines. so, at least in a mouse system, in a monkeysystem, it looked like there were some promise in terms of offering protection against zikavirus. can you tell us about these developments,your cautionary note about these developments and also talk about how even if we found areally good vaccine, how that has to translate

in terms of controlling this outbreak? >>ian lipkin:well, there's several challenges with vaccines. so, this is clearly the least expensive approachthat we have, and it's the only one that we can really implement for the millions of peoplewho are going to be at risk for infection with this and other viruses. now, what we try to do is we find some regionof the virus that's capable of inducing what we call protective immunity because thereare many different types of immunity. some will result in what we call neutralizingantibodies that will bind to a virus or bind to a bacterium and prevent it from enteringa cell or from causing disease or from releasing

some sort of a toxin that has a deleteriouseffect. one of the problems that we frequently have,however, is that some of these vaccines may not work as well as we planned, so we tryto test them in animals first. and we want to make sure that they can protectthose animals. now, we have many drugs that work beautifullyin mice that don't work so well in humans. so, we try to go to other models as well. the best, of course, are non-human primatesand we want to demonstrate that they're protected. and what we want to do is to replicate allof the various circumstances that might pertain with a human infection.

so, if you're talking about someone who'sgoing from new york city who's at risk for going to some area in the world where there'syellow fever and they've never seen a yellow fever-related virus, you give them the yellow-fevervaccine and as long as it's safe and you get reasonable protection, you're happy. if, on the other hand, you're talking aboutvaccinating people in a part of the world where there are related viruses, you haveto be concerned that the cross-reactive immunity against one virus doesn't aggravate the diseasethat might occur if they see the second one. so, with dengue virus, there are four differenttypes in a majority sense of dengue viruses. and you want to make certain that any vaccineyou develop for dengue virus protects against

all four. otherwise, you have to worry about the factthat the vaccine response, which is excellent for two of the types of dengue virus mightmake subsequent infection with the other two worse. the same thing pertains here with zika. so, the first thing we try to do is we demonstrateefficacy in an animal model. our preference is to have a second animalmodel that's closer to humans to prove that it's effective there. then we test it for safety in humans, andthen there's this last concern, which i haven't

mentioned at all, which came up with the lymevaccine, which was quite unfortunate because, frankly, it was a great vaccine. but we don't use it anymore because peoplewere concerned that making an immune response to the lyme vaccine was going to actuallyresult in autoimmune disease. the evidence in favor of that is so weak thati wasn't worried about it, but the companies that manufacture the vaccine decided thatthe risk to them was too great to proceed with this as a trial. so, vaccines are tricky. now, you mentioned diagnostics.

we are going to get back to diagnostics, ornot? >>susan perkins:i would love if you would tell us a little bit about it. >>ian lipkin:okay. so, cathy was talking about the ways in whichshe counsels patients and the kinds of things you can do. we have two broad types of diagnostic tests. and jay supervises a huge group that employsthese tests in the city department of health. but they basically boil down to those thatdetect genetic footprints of the virus and

those that detect antibodies to the virus. now, the first test that's going to be positivewith an infection is going to be the one that's genetic because you're actually detectingthe virus in the body, whether it's in the seminal fluid or it's in the blood or it'sin the tissue or amniotic fluid. that's where you're finding the virus itself. the antibody response doesn't appear untilabout a week to two later, and it tends to come up, gets very high, and then it slowlybegins to drop off. so, if a woman came into her clinic and saidi'm concerned about it and i was there a month ago, would you do the genetic test?

probably not. you might do it anyway, but if it was negativeit wouldn't provide any real reassurance. it might be useful if you tested the seminalfluid on her partner, but there she needs to look for the antibody test. and one of the things that's been quite soberingwas a report that came out of columbia suggesting that the greatest risk they found was in womenwho actually didn't recall having an infection at all. so, if you don't have any sort of experiencethat's consistent with the zika virus infection, it doesn't mean you're safe.

you have to have the additional laboratorytests. and the laboratory tests are, frankly, notvery good. the genetic test is great, and we can distinguishzika and dengue and everything else. but the serology is tough because there isthis problem of cross-reactivity and we can't be absolutely certain - even with the goldstandard neutralization test, which everyone uses as the second line - that in fact wecan be certain that it was zika and not dengue. because there is this problem with cross-neutralization. now, we are trying to, in fact, work withjay and some of his colleagues in trying to find very small peptides, very short fragmentsof protein, that can distinguish between antibodies

to zika and antibodies to dengue. so, stay tuned for that. and even if we found this vaccine againstzika, it's not on the shelves tomorrow, right? i mean, i think that's one thing people haveto appreciate, that it takes time not only to go through the safety trials, but to rollit out, and then getting it out to the people that need it is a huge challenge. so, we're about to turn it over to your questions,but i want to ask one final one to jay here. and that is to be very specific about newyork city. so, what is your department doing to continueto monitor this, the plans for responding

to it? and i would love it if you would maybe putthis into some kind of context with other health risks. so, influenza kills hundreds of thousandsof people a year. many people get malaria locally. how does zika fit into this scheme of thingsin terms of what are day-to-day things we need to be worried about? so, maybe the l train, getting zika. put that into perspective.

>>jay varma:no, i know. i think this is - i think what we're reallychallenge with here is a lot of uncertainty. and i think that's what worries us. and, of course, even more important it worriesall of the people who are potentially at risk or have already been exposed. when we think about risk in public health,we think about two things. we think about what is the likelihood of theevent occurring, and then what are the consequences if that event occurs. so, we in public health are often times concernedabout events that occur very commonly.

and even if the consequence of them isn'tgreat every time, the fact that they occur so often is a real concern. so, the flu is a perfect example. a lot of people get the flu every year. very few people who get the flu die from it,but because you have so many people infected it still adds up to thousands and thousandsof deaths every year in the united states. now, zika presents a unique challenge becausefor the average new yorker who stays in new york and doesn't go anywhere else, the riskis incredibly low of you contracting zika. not just because of the work we're doing,but just simply because of the climate that

we have here in new york. but we know that one of the things that'sgreat about new york is you've got flights everywhere in the world. we get to interact with people from all overthe world. so, the risk is not zero and it's not evenclose to zero. it's a lot higher than that of that eventoccurring. and then you have the other issue, which isthe consequences of the event. and i think what's always been most concerningto me about zika and what's really truly worrisome about it is that it doesn't hurt the personwho gets infected, but it hurts your ability

to reproduce. and as a species, that is a dangerous thing. if you really wanted to cause harm in theworld, you'd stop people from passing on their genetic material to the next generation. so, we think that the risk for the averagenew yorker is very low, but because the consequences are high and because of travel, it's somethingthat we're doing a lot about. what are we working on? all of you have these yellow cards there. one of our biggest and most important thingsthat we do is we educate the public.

we want to get facts into your hands, so youcan make informed decisions that are right for you and that are right for your families. so, you'll see these ads on the subway. you'll see information there. you can go to our website. we have lots of information, not just forall of you, but if you're a medical doctor and you need that information. we're working very actively with the medicalcommunity. it's a huge challenge, as cathy can say fromthe ob perspective.

this isn't something an ob/gyn doctor is usuallyworried about. we usually work with er doctors or infectiousdisease doctors. but they're having to come up with an entirelynew workflow for how do you screen women, ask them the right questions, make sure theyget tested. there's a lot of uncertainty with these diagnostictests, so we're spending a lot of time working on this. we have over 230 cases that have been diagnosedin new york city since january. twenty-four pregnant women. in addition to those women who are confirmed,there are a number of women who have these

indeterminate tests where they're not reallytruly infected, but we can't tell them for sure that you're out of the woods. and this presents a lot of challenges. so, we're doing a lot of work with them. and then as it relates to mosquito control,the strategy that we've taken in general is that when we can do an intervention, evenif the risk is low, if we can do an intervention that's safe to bring that risk even closerto zero as possible we're going to do it. so, even though we know that the aedes mosquitothat we have here in new york city is not very effective at transmitting it, we've adaptedour mosquito control program.

so, in the past to control west nile viruswe sprayed primarily at night time. we sampled mosquitoes when they're positivefor west nile. we do mosquito control in those neighborhoods. we've taken that infrastructure and changedit a little bit. now, because these mosquitoes are very aggressiveat biting during the day, because they can breed in very small amounts of water, we'repushing a message out there - and this is a message that you can take home and act on,which is that if there is water anywhere that's standing and stagnant - and it can be as littleas - we're not talking about having a backyard pool that isn't clean.

we're talking about even small amounts ofwater. you can address that in your homes. empty out flower pots. don't have even soda cans that are sittingaround that have water because those mosquitoes can lay their eggs in them. if you see standing bodies of water elsewhere,you can call 311. we're advertising this a lot, and our callsare vastly exceeding what we've had in previous years. collecting standing water, we put somethinginto that standing water in large, marshy

areas called larvicide, which kills off theeggs of those mosquitoes. and we're going to sample in a lot more areasto look for the density of these aedes mosquitoes. we haven't needed to spray to kill off theadult mosquitoes; what's called adulticiding, but we're prepared to do that if these effortsat controlling standing water and killing off the eggs doesn't work. all right, i'm going to open up the floor. we've got some mics to go around, so if you'dlike to ask one of our panelists a question, raise your hand and kira or somebody willbring a mic around to you. >>question:hi.

thank you for that wonderful talk. i had a question from a public health standpoint,and i was wondering if any of you wanted to offer an opinion on the current situationwith the rio olympics coming up very quickly because as you were discussing, transmissibilityis a really, really important factor to consider in these kinds of epidemic situations. and part of the reason why we're worried innew york is because we're so connected with the rest of the world. and i was particular interested to know ifyou guys think there will be a great impact on the spread of zika that results from theamount of international traffic that's now

headed to brazil, which from my understandinghas a very specific strain of zika that is either more transmissible or more virulentsomehow. so, i was hoping i could get your opinionon that. >>jay varma:yeah. i'll answer the question about new york, andif everybody else wants to weigh in on the global situation. from our perspective, again, what makes newyork city great is our connectedness to the rest of the world. we have over five million arrivals every yearfrom zika-affected regions into the area airports.

and so travel to and from the olympics forus is really just a drop in the bucket, i think, compared to all of that. so, from our perspective, specifically lookingat travel to and from the olympics, to new york, it's not a huge concern for us. we're already concerned about the fact thatwe have - the vast majority of the cases that have occurred in new york city are peoplewho have traveled to the dominican republic. that's not because the dominican republicis more dangerous than anywhere else. it's because we have over a million travelersto and from the dominican republic every year; people visiting family, people going on holiday.

so, from our narrow perspective just lookingat the city, it's not as big a concern. and i don't know if cathy wants to talk aboutthe global perspective and introduction into other places. >>catherine spong:yeah, i agree with you. i think that's been the take-home messagethat the amount of travel that we get to and from the olympics is going to also be offsetby people not traveling because of the olympics there. so, it's not going to really make a big difference. >>ian lipkin:the other thing - and this is sort of a glass

half empty way of looking at it - is thattheir climate is the reverse of where we are so, they're heading into winter, which isnot the peak season. so, in fact there may be a reduction in mosquitoburden. that said, i would not advise my daughter,were she pregnant, to go participate in the olympics, but that's probably for two reasons. so, let's say that a female does travel anddoes contract the zika virus and her male partner does not have it, and then plus eightweeks later they want to have a child, is there any risk of it still being birth defects? or are there proven cases where they're fine?

>>catherine spong:so, the information that we have is for someone who contracts zika while they are pregnant. and so that's why the recommendation is ifsomeone has zika virus to wait a period of time to allow the virus to go away and toallow enough time - so eight weeks to before they were to try to become pregnant. for a man, the recommendation is longer simplybecause it stays in the semen for a longer period of time. we don't have additional information to lookat a subsequent pregnancy that there are complications. we don't have any information that there isa complication there.

>>ian lipkin:but to take that one step further, the question might also be whether or not there's evidenceof female to male transmission, which would then set the stage for subsequent infection. and the answer to that one is i have absolutelyno idea. i've not heard it reported, but we do knowit the other direction. >>catherine spong:that's correct. so, you've mentioned that zika's been aroundfor quite a while. i was wondering if you could comment on anyresearch, if there is any research, on potentially finding a wildlife reservoir, if you couldcomment on that.

>>ian lipkin:yeah. so, the question - and i should have addressedthis in the introduction to zika virus. i got too excited talking about viruses ingeneral. it was first identified in a monkey. so, we know that monkeys are capable of sustainingzika virus infection. and it would not surprise me if there werewildlife reservoirs. but right now the best reservoir seems tobe humans. >>question:i was just going to ask if people need to worry about their dogs?

>>jay varma:not that i - you're looking at me. i don't know. i don't think so. we don't know. i mean, the reality is like a lot of thingswe don't actually know. but as ian mentioned and from what we knowalready, it's non-human primates and humans that are the primarily reservoirs, but staytuned. >>question:hi, thank you. it seems it's very clear that women infectedduring the first trimester have a great risk.

and you mentioned that waiting eight weeksmight decrease the risk. how effective is the testing right now bothfor women and for men? so, say a woman is exposed, you wait the eightweeks, can you test the man at that point? or how much can we trust those tests at thispoint? >>catherine spong:so, there was a lot so questions in your question. and so we'll start with some, and i'll letian take over for some of the testing as well. related to the timing in pregnancy - and youbrought up that in the first trimester there's associated risk - one of the biggest questionswe have is what really is that risk. what is the degree of that risk, and how canwe counsel women about it?

in fact, there was a study that looked at88 women who had symptoms consistent with zika in brazil and what were their outcomes. and they followed subsequently with ultrasoundsa little over half of these women. and what they found was in these symptomaticwomen, 29 percent had complications in the fetus. and these complications ranged from thingslike microcephaly to fetal loss or still birth. now, this is only in symptomatic women. and this included infections in the firsttrimester, the second trimester and the third trimester, which is very concerning.

in fact, that to me was the most concerningpart of the report. that even an infection in the third trimesterhad so many complications. as an obstetrician, typically we think aboutrisk and think, well, if you haven't an infection in the first trimester or an insult of anytype in the first trimester, that's when you're going to have the most harm. because that first trimester is when all theorgans are initially forming. then, again, in fact in the second and thirdtrimester, those organs are continuing to form. i mean, in fact if you look at a developingbrain across gestation, it's remarkable how

much brain structure and formation is stilloccurring in the second and third trimesters. since this virus is so neurotrophic - it reallyseems to go after neural tissue, it might suggest why we see even significant complicationsin the second and - with infections in the second and third trimester. one of the problems i have is i don't havea lot of information about how to quantify that risk for patients. and i don't have any information about asymptomaticinfection. in fact, i only have occasional case reportswhere a woman never knew she had zika, but clearly the child has the sequela associatedwith zika virus.

so, it's likely that even without symptoms,many of these complications can still occur. so, for a woman - your second question askedabout diagnostics. and ian did a really nice job kind of walkingthrough the different diagnostic tests. if someone has the symptoms of zika you cantest using pcr testing - the genetic-type testing - and really know does the personhave zika or not. those are really easy tests that are verystrong for us to be able to tell someone whether or not they have the infection. if in fact you've passed that period - it'sa couple of weeks out - you're going to be looking at that antibody response.

and that's where the diagnostics aren't asstrong. i think in the future - and ian's workingon this and others are working on this - we're going to have some really solid diagnostictests for zika virus. but right now we don't have those. >>jay varma:just for those of you who are new york city residents, if you are exposed or you havea family member that's exposed and you need to get tested, you go to your doctor. your doctor has a number that they can callat the health department. it's wildly available.

just call our - you can even just call 311and they'll connect you to us. what we do is we have the doctor - we havehim call us. we make sure it's appropriate for you to gettested because you really were exposed. you'll provide two tubes of blood and onesample of urine. and that will go to our public health laboratory. the first test that we'll do is this pcr teston both the blood sample and the urine sample to test to see if you have the genetic fragmentsof this. and then the second test that we'll do - ifit's appropriate and for women who are pregnant it's done on all of them - is this test tolook at antibodies.

and i think really the big challenge we haveis that this genetic test is great for people who have had symptoms and it's positive. then we know for sure that you had it. it's making for sure that you didn't haveit that still remains a problem. >>question:mine isn't related to pregnancy. mine is a concern with the columbia reportsof guillain-barre syndrome. and columbia had more of those reports thanbrazil did. i live in brooklyn, which has a fairly largecaribbean/west indian population. most have had dengue as a child or when theyvisited home.

and that seems to increase the complicationsof zika. or am i misreading the current literature? >>ian lipkin:so, the question, first of all, is whether this particular disorder guillain-barre syndrome,which for those of you who don't know what this is, i'll describe it. it's essentially an immune attack on the insulatingsubstance around peripheral nerves. and as a result of this attack on the insulatingsubstance, you lose your ability to walk, to control your fingers. and, in some instances, if it progresses farenough you can actually lose your ability

to breathe. and as the attack recedes and the immune responserecedes, you get the restoration of the insulating material, and then hopefully you recover. but some people take months or even yearsto recover, and some people never recover fully. now, the evidence linking zika to guillain-barreis less strong than the evidence linking it to the microcephaly that cathy's been talkingabout. there are reports every few years of anothervirus or another bacterium that is linked to guillain-barre syndrome.

but just accepting for a moment the argumentthat there is a relationship - and i'm not persuaded yet, though, it's highly plausible. the question then would be does the infectionwith dengue increase the risk that if you get exposed to zika you will have this additionalcomplication of guillain-barre? and the answer is it's biologically plausible,but it hasn't been proven. would not surprise me, though. it was stated that it's harder to have a testshowing that you don't have the disease. is that because there's no way to definitivelyknow how long it lays dormant? is that correct?

>>ian lipkin:no. let me just follow through the diagnostictesting paradigm because what jay was describing for you was the way in which patients wouldscreen through physicians. and there are ways to be absolutely, unequivocallycertain. you do the genetic test first. first, you have to look for evidence thatsomebody could have bene infected. if you don't find the genetic fragments - i'mreferring now to a woman, not to a man because we've already talked about differences inthe compartments that might be positive. and as he said, you've tested the blood andyou've tested the urine, and that's negative.

you then do an antibody test. and forgetting about the cross-reactivityissue, if it's stone-cold negative at that point you still need to do another test afew weeks later because you might have been in this eclipse window when the genetic testis negative and the antibody test hasn't yet come up. but if you do the genetic test and it's negative,and you do the antibody test and it's negative, and four weeks later you have a negative antibodytest, then you haven't been exposed. at least you haven't been infected. you might have been bitten by a mosquito withzika, but the infection didn't take off.

now, all bets are off if you're someone who'simmunosuppressed or in high doses of steroids for any reason or you have some sort of unusualmedical condition, which prevents you from mounting an immune response. so, we're talking about the average healthyperson. >>question:thank you. i'd like to get a comment on the lysogenicstate. you mentioned something about the lytic state,but you didn't say anything about the lysogenic state. and also its mutation rate if you know anythingabout that.

and the last one is you mentioned calciumdeposits in the brain, and i was wondering if you could say something about the cognitiveskills of these. and that's it. >>catherine spong:i'll let you start, and then i'll finish up. >>ian lipkin:so, mutation rates - viruses come in many different flavors. and some viruses are made of dna, which isa very stable molecule for the most part, particularly if there are two copies of itand they ride side-by-side. and as the virus makes more of itself, there'sa proofreading.

it checks - on this one says, no, we screwedup here and it backtracks. and then it makes the appropriate substitution. rna viruses, in contrast, are continuallyevolving and mutating. now, we don't yet know, in contrast to someother viral infections that i won't talk about right now - but in contrast to some of theones we already have identified, specific mutations that make them more dangerous. we don't have anything yet to suggest thathas occurred with zika. but the concerns that jay was raising aboutthe fact that we have other strains of this aedes mosquito that might not be the bestvector for carrying this virus, it might evolve

to become better adapted to that particularmosquito strain. in which case, it could be more effective. or god help us it adapts to a culex, whichwe have in abundance in new york city. so, the answer is we have to continually trackthese viruses. we have to figure out how they behave as wereplicate them in culture systems and in animal models to figure out whether or not they arein fact becoming more dangerous. >>catherine spong:so, you asked a question about the calcifications in the brain and the cognitive outcome. and those are two different things actually,or they could be.

because the fetus, as it's affected, dependingon the timing of that infection and what happens in pregnancy you can get calcifications inthe brain where you have areas that you can see white spots on an ultrasound or on anmri scan or a ct scan. and depending on where those are might affectdifferent parts of the brain. so, if they're in one part of the brain thatcontrols a motor function, you might have an abnormality there. if those spots are in a place where you havea vision function, it might impair the child's vision. now, that said, zika has been shown to havemany different malformations in the brain,

including not only microcephaly where youcan have a small brain, that brain can also be abnormal. there have been case reports showing wherethere have been absence of specific structures in the brain and where there have been verylarge ventricles in the brain. depending on which of these outcomes has occurredand the timing of when that occurred is going to impact what happens to this child. now, we don't have good information to knowwhat is the long-term impact, but it is clear from other infections and complications inpregnancy when you see some of these abnormalities that these children will have complications,whether it affects their motor or their iq

long term in life. and one of the biggest concerns is to bestunderstand how should we evaluate, monitor and manage these children for the long term? and we don't have good information on that. we will be having a workshop at the nih inthe end of september to really try to address the child to say given what we know - thesebrain malformations, these eye malformations, these growth abnormalities - how should weevaluate these children? how should we monitor then, and then how shouldwe treat them? and the way that we can do that is to takewhat we know from other infections and other

complications that result in this same outcomeand say how do we treat those, how are those similar or different to zika, and then whatrecommendations could we come up with? what is the best evidence we have on how toevaluate these children and manage them? and then based on that, the professional societiesand organizations can come up with a plan for how we care for these children. and i think that is one of the big impactsthat we need to be able to address. for women not trying to get pregnant - activelytrying not to get pregnant, but with children who are girls, who are also not getting pregnant,is this a real concern? i feel like this is very specific population,which we are rightly concerned about, but

for everybody else apart from the fact thatif you have it in your blood you can then infect a mosquito, which can then infect anotherperson, this feels not something to worry about. is that accurate? i mean, basically what we are focused on iswomen of reproductive age who are at risk of getting pregnant or trying to get pregnant. i mean, without question if you have to pickany group that we're focused on most, it's that group right there. so, you're absolutely correct.

if you are an otherwise healthy adult or childthat is traveling to those areas, you're not trying to get pregnant, you're not at riskof getting pregnant because of your age or your birth control status, the odds of havingsomething bad happen are pretty low. this is a very - the vast majority of peopleget no symptoms at all. that 20 percent of people that do get symptoms,the symptoms tend to be fairly mild. so, yes, it is very reassuring in that regard. i think what gives us pause and the reasonwe are here in new york city and at the national level and in the academic community and focusedso much on it is this level of uncertainty about complications.

but you're absolutely correct. from everything we know right now, everybodywho gets this illness - if they're not a pregnant woman - the outcomes are very mild, exceptfor these unusual neurological manifestations, which can occur with other infections as well. >>ian lipkin:except, again, if you're immunocompromised it's a very different story. so many of these virus infections or bacterialinfections that are otherwise innocuous can become devastating. >>question:it's related to the last question actually.

so, for people that's not planning to getpregnant i heard that having dengue increase your chance of getting zika. does it work the other way around? so, i'm not trying - i'm not planning on gettingpregnant, but i do travel to singapore quite regularly. so, meaning that if i get zika, does it increasemy chance of getting dengue there? >>jay varma:i don't think we know the answer. i think it's the [unintelligible 61:51] unfortunatething. i think the one piece that i would come backto is a question that we have about the risk

in pregnancy that what is making it more severein some women. and there is the thought that perhaps by havingan exposure to another infection such as dengue may potentiate the risk of zika itself. we don't know that answer, but that is somethingthat we need to study and we need to understand. so, we're doing this large study, and oneof the things that we will be collecting and trying to look at is this either prior exposureor co-exposure with another infection and whether that has any effect on the risk ofzika in pregnancy. >>ian lipkin:so, what we do know is that at least three scientific groups independently have lookedat the impact of antibodies to dengue on infectivity

with zika in tissue culture, if you know whati mean by that; cultured cells. and two of them have done this in animal modelsas well. and what's been shown consistently by thesethree groups is that there's some antibodies which will in fact increase the rate at whicha virus can get into certain types of cells and increases the amount of virus that isproduced by those cells. analysis using structural biology has shownthat there are other regions within some of these viruses - and this is the most promisingvaccine work that i've seen in terms of design [unintelligible 63:41] pasteur - suggestingthat there's a region where you can make antibodies that will neutralize not only all types ofdengue viruses that are known, but also zika.

so, as people begin to try to develop vaccinesusing these sorts of tools, you can make predictions about which designs are most likely to beeffective. >>question:back in august of 2003 i had a stem cell transplant as a cure for leukemia, and my wife and iare planning to travel to the dominican republic. should i be concerned? in august we're planning to travel to thedr. >>ian lipkin:what's your immunological status now? >>jay varma:we are not - we don't currently have a recommendation that's focused on people with immune-compromisedconditions.

and i think that's because we just simplydon't know enough. our focus has been primarily on, as we said,women of reproductive age. >>catherine spong:that would be really important for you to talk with your physician about what is yourstatus and how much of a risk is it for you. i think it's difficult without having allthat information to really be able to provide you guidance, but i think you're right ontarget to be asking those critical questions. and the reality is the risk of these other- dengue is a very serious and very severe illness. chikungunya is, as well, too.

so, it's not- >>catherine spong:it's not just zika. >>jay varma:it's not just zika. there's a lot of mosquito-borne infectionsin this world. >>question:since you can remain unsymptomatic, but still have the virus, if a couple together travelsto the caribbean and comes back symptom free, but does want to get pregnant, i understoodthat you said a woman should wait eight weeks and the male longer. did you say six months for the male?

>>catherine spong:so, if both are asymptomatic - they had no symptoms at all - it's eight weeks. if a man is symptomatic or a man is knownto have had zika - a positive test for it - six months. >>question:okay. minus the testing, though, they could stillboth be infected without having symptoms. so, will people be tested just because theytraveled and want to get pregnant? >>jay varma:we're not currently testing people who - we're advising them to follow this guidance.

and the challenge with - as ian mentioned,it is possible in certain laboratory settings to test, for example, the semen. and we get request like that. well, i want to be tested to make sure thati'm clean. the danger with that and the challenge withthat is you can't be sure that a negative test really means that they don't actuallyhave it. it may be that shedding is intermittent. in other words, it doesn't occur all the time. and so that's one concern that you have ontop of whether the test actually performs

the other challenge is even if you do detectit, what you may be detecting is just the remnants of this virus having been in yourbody, as opposed to a virus that truly has the ability to infect other people. and so in addition to the fact the test isn'twidely available in any reproducible form, that's the other reason we don't reliablytest people, say, their semen, for example. >>susan perkins:and we're just going to take a few more questions. >>question:do we know enough about zika to worry that it might evolve rapidly like influenza virusand produce new strains in a very short period of time?

>>catherine spong:that's ian. >>ian lipkin:if i had a crystal ball like that i'd retire. thank you for this. i'm reacting to the recommendation of notleaving the can of diet coke out because of the breeding possibilities in such small amountsof water. and i have a toddler, and the majority ofthe parks that he goes to are sprinkler water parks. and he's too young, at least according tothe pediatrician, to start using deet and other strong repellents.

so, i was wondering what thoughts are withvery young children who spend all of their time over the summer in sprinkler parks. >>jay varma:i would say, first of all, the sprinkler park itself doesn't necessarily represent a standingwater risk unless for some reason that water sits there outside for long periods afterthat because there's a pothole or something else like that. so, that exposure isn't that much of a concern. and then the second is that there are mosquitorepellents that are quite safe at all ages. and so you can check both on our website,on the epa website, for recommendations about

which ones to use. >>susan perkins:last one in the front. >>question:[unintelligible 68:54]. >>jay varma:correct. the mosquito that's causing these wide epidemicsthroughout the caribbean and latin america does not exist in new york city. we've tested over a million mosquitoes innew york city in the past 10 years. we've never once found this type of mosquito. it's in a cage.

>>catherine spong:except in the case in the back. >>jay varma:exactly. we keep it in a cage here in case we everwant to let it go. >>catherine spong:it's a little magnified. >>jay varma:exactly, yeah. it's like smallpox. it's only in one lab. >>question:back to the question about children's exposure risk, isn't it not a problem if your childgets zika virus?

i mean, your young child isn't going to havea baby, so it doesn't matter. correct? >>jay varma:i mean, again, as we're saying, for the vast majority of people, whether you're a childor whether you're an adult or somebody else, this is not a concern. it's the concern is really focused on, unfortunately,women of reproductive age. i mean, i think just to emphasize for people,we want to reassure people about the work that we do here in new york city, the wayswe try to control it, about being realistic about what the actual risks are.

from a public health level and the reasonpeople like me are spending a lot of time at all levels who's doing it is somethinglike 40 percent of pregnancies in the united states are unintended. so, we have to operate under the assumptionthat any woman of reproductive age is potentially at risk of having a pregnancy. and because this infection is potentiallyvery devastating, we have to plan for those circumstances. >>susan perkins:all right. i want to take just one last minute to thankour panelists ian lipkin, catherine spong

and jay varma. thank you so much for being here with us.