As Zika spreads, WHO facing calls to take more urgent measures
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As concern mounts about the Zika virus epidemic sweeping through Latin America and the Caribbean, some global health experts are questioning why the World Health Organization is not responding more urgently to the outbreak and convening experts to consider emergency measures.

A number of global health experts are now calling on the Geneva-based WHO to reach for a powerful tool that would help it guide the world’s response to the virus — feared to be causing an increase in cases of a syndrome that triggers paralysis in some people and serious birth defects in infants born to some women infected during pregnancy.

Under the International Health Regulations — a treaty governing all WHO member countries — Director General Dr. Margaret Chan could establish a panel of experts, known as an emergency committee, to advise her on how the world should react to the epidemic.

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A spokesman for the WHO told STAT there so far has been no discussion of convening an emergency committee in the case of Zika. Some experts say that’s a mistake.

“I believe that it is past due for the WHO DG to convene an emergency committee for Zika,” said Lawrence Gostin, director of Georgetown University’s O’Neill Institute for National and Global Health Law. “Convening an emergency committee and issuing detailed guidance on national preparedness, travel advisories, and punitive measures is now urgent.”

Preben Aavitsland, one of the drafters of the revised International Health Regulations, which came into force in June 2007, agreed the Zika situation warrants using the IHR tool, in part because of concerns that the virus is causing a spike in cases of microcephaly, a condition in which newborns have abnormally small heads.

“My personal opinion is definitely, yes, an emergency committee should be convened,” said Aavitsland, Norway’s former state epidemiologist. “It may discuss the evidence for a causal link between Zika virus infections and microcephaly, the options for prevention, the research needs, whether the situation constitutes a PHEIC, and if so, what recommendations should WHO give to prevent spread.”

A PHEIC — pronounced, unfortunately, as “fake” — is a “public health emergency of international concern.”

Chan created an emergency committee to advise her on Middle East respiratory syndrome — MERS — in July 2013. That committee has met 10 times, each time concluding MERS did not at that point constitute a global health emergency.

But the panel has offered the WHO advice on how to handle the ongoing outbreak, which has largely but not exclusively infected people on the Arabian Peninsula.

Georgetown’s Gostin was a member of the international expert panel that assessed the global response to the West African Ebola outbreak. Its report called for a major revamp of the WHO’s emergency response capacity.

He said convening an emergency committee on Zika virus would send a message to countries and to agencies that fund biomedical research and global health responses: Money should be mobilized to help in the response, and unaffected countries that have the type of mosquitoes that can spread Zika virus should prepare for its arrival.

CDC
CDCCountries and territories with active Zika virus transmission

Chan created an emergency committee to help her during the 2009 H1N1 influenza pandemic. She again reached for the tool in 2014 to steer the attention of world leaders to the then-struggling effort to eradicate polio. A committee was convened as Ebola devastated three West African nations in August 2014 — weeks too late, a global chorus of critics contend.

Though the Ebola outbreak is nearly over and polio spreads in only two countries at this point — Pakistan and Afghanistan — the emergency committees set up for those issues still meet every three months.

A WHO spokesperson, Christian Lindmeier, said the agency has not established a Zika panel because “more evidence and data” are needed.

Gostin, for one, thinks the WHO is again missing the opportunity to take the lead on a pressing global health issue. “Zika is present in virtually every region of the world, and there is now a potential association with congenital abnormalities in fetuses and newborns. WHO should have learned its lesson from Ebola when it was so late to call a PHEIC,” he said.

Zika is not a new virus. It was first discovered in Uganda, in central Africa, in 1947. It normally causes mild flu-like illness in people; as a result, it has been studied relatively little.

Alex Hogan/STAT Zika virus, which can be transmitted by mosquitos, has exploded onto the world stage in recent weeks.

But starting in 2007 the virus began popping up in places where it had previously not been seen, infecting populations where there was no immunity to it. Hints that there might be unexpected and serious consequences of infection started to emerge.

Last spring the virus arrived in Brazil, igniting an explosive outbreak. By fall, some women who were infected in pregnancy began to give birth to babies with abnormally small heads. Brazil estimates it has seen a twentyfold increase in microcephaly cases since its Zika virus outbreak began.

Even earlier, in July, there were reports of Guillain-Barré syndrome — which causes paralysis, most of the time temporary — in some people who had been infected with Zika. More recently, El Salvador — also in the grips of a Zika virus outbreak — reported 46 GBS cases in a five-week period from December to early January. That is nearly three times more than the country would normally see in that timeframe.

“Something weird is going on here,” said David Fidler, a professor of international law and global health security at Indiana University at Bloomington.

Fidler sees more gray than Gostin does when he mulls over whether the Zika outbreak merits establishment of an emergency committee. Emergency committees have not been established to deal the spread of the dengue virus, nor of the chikungunya virus. Both of those viruses cause more severe disease than Zika virus.

But one of the steps emergency committees routinely recommend is that countries unaffected by an outbreak not make matters worse by slamming closed their doors to travelers from affected countries.

No country has taken that step yet to try to stop the spread of Zika virus. But the United States and Canada have both urged pregnant women to avoid travel to places where the virus is spreading.

Fidler isn’t criticizing those decisions, but he can see the potential for the situation to cascade. He admitted that in the back of his mind loom questions about the Rio Olympics, set for August.

“The politics could go where epidemiology would not advise, which makes it incumbent on WHO, with the authority it has under the IHR, to play a leadership role in the management of this new public health threat.”

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