Transcript: CDC Director Addresses National Press Club

Dr. Tom Frieden: When an earthquake hits, we understand the need to respond.  Now, imagine if you had the power to stop an earthquake.  We, together, using the tools of public health, have the power to stop the health equivalent of many earthquakes that happen around the world.

The latest challenge we’re dealing with is Zika.  This is unprecedented and tragic.  It has been more than 50 years since we’ve identified any pathogen that can cause a birth defect.  And we have never before identified a situation where a mosquito bite could result in an infection that causes a devastating birth defect.  It is unprecedented.  It is tragic.  And it is now proven.  We know that Zika causes microcephaly and other birth defects.  But there is an enormous amount that we still don’t know.  We’re still learning more, literally every day, about what Zika causes and how to prevent it.

The top priority is to protect pregnant women.  And that focus has to be the guiding principle for our work everywhere there is risk for Zika.

Memorial Day weekend heralds the start of mosquito season in the U.S.  We have a narrow window of opportunity to scale up effective Zika prevention measures.  And that window of opportunity is closing.

I want to spend a moment to recognize a remarkably generous donation by Bayer to the CDC Foundation to support a comprehensive program to confront the Zika threat in Puerto Rico.  Bayer is making a very substantial donation that will enable us to do a number of things that control mosquitoes and to support women who choose not to become pregnant during this time with effective, modern contraception.  They were also at CDC where Ed was present along with other officials, accelerating the work to protect people in this country.  It’s an example of the public sector, the private sector, and the philanthropic sector coming together to do what we couldn’t do effectively on our own.  We thank you for your wonderful work supporting this effort.  [ applause ]

It has been less than five months since we first saw conclusive evidence that Zika may be the cause of microcephaly.  In these five months we’ve learned an enormous amount.  And I’ll take you through ten things that we’ve learned in these five months.

First, it is an extraordinarily complex response.  In fact, of all the responses I have overseen, it’s probably the most complex.  We have involved almost every single part of CDC.  We’ve had more than a thousand of our staff involved.  Whether it’s mosquito control or virology or sexual transmission or obstetrics or newborn care, many, many parts of our agency are fully activated to support the response.

Second, it’s now clear that Zika causes microcephaly and other birth defects.  I vividly remember sitting with Dr. Zaki, our chief infectious disease pathologist, and having him show me the very special stains that he had done to show that Zika virus actually invading the neural tissue of newborn infants and destroying it.  This is a horrible thing to see.  It is just the kind of thing you would never want to see.  And yet to understand that when a child is born with microcephaly, it’s not because the skull was malformed.  It’s because the virus destroyed the brain cells.  And the skull collapsed around the demolished or devastated brain.  It’s a horrible situation.

Third, we have now seen clear evidence that even asymptomatic infection with Zika during pregnancy can result in microcephaly.  And we know from past studies, about four out of five Zika infections appear to be asymptomatic.

Four, Zika almost certainly causes Guillain-Barre syndrome.  This is temporary paralysis.  This isn’t so surprising.  We’ve seen it with other infections.  It is generally treatable.  That’s not what’s so unusual about Zika.  What’s so unusual about Zika is the threat to pregnant women.

Five, diagnosing Zika is hard.  But we’ve made enormous progress.  CDC laboratory scientists have optimized testing so we now have a rapid, highly sensitive test that can be used in urine or blood that can pretty accurately detect the virus in someone who is acutely infected.  We’ve disseminated them to a hundred labs around the U.S. and in countries around the world.  We’ve also improved the CDC mac-ELISA. It’s not perfect but it’s the best test out there.  As well as a more rapid test or a more complex test to try to determine which of several similar infections the person may have had.  It’s a neutralization assay.  We’ve provided more than a million of those tests.  So testing is hard, but we’re making progress.

Six, controlling this mosquito is really hard.  Aedes aegypti is the cockroach of mosquitoes.  It lives indoors and outdoors.  It bites during the daytime and the nighttime.  Its eggs can last for more than a year.  They can hatch in a drop of water.  In parts of the U.S. and Puerto Rico, they’re highly resistant to certain insecticides.  They prefer people, so they generally spread disease among people.  And when they take a blood meal, they’ll often bite four or five people at once.  So they’re capable of rapidly spreading the infection.  There is no example of effective control of this mosquito in the modern era.  I vividly remember in a trip to Puerto Rico, our lab team had set up a laboratory that hatched mosquitoes.  And they were testing them for resistance.  We put them in a bottle coated with insecticide to see whether they’re knocked down or not.  And to see them in a bottle that had been coated with what should be a very effective insecticide happily flying around minute after minute, hour after hour, shows us how important it is that we improve the methods we have of controlling mosquitoes.

Seventh, there are also other routes of transmission.  We did not expect that sexual transmission would be as common as we’ve seen it.  We’ve had 10 documented cases in the U.S.  We’ve never had sexual transmission of dengue or West Nile, but Zika can spread sexually.  That adds a new level of risk and a new message that if your partner is pregnant, and you’ve been in an area with Zika, use a condom.  Also blood safety.  Theoretically it’s possible that there could be transfusion-associated Zika.  That’s why we’re so grateful for Roche and the FDA, they’ve come out with a terrific, highly sensitive test already being used in Puerto Rico to screen the blood supply.

Eighth, Puerto Rico has a particular challenge.  They were dealt a bad hand by nature when it comes to mosquito-borne disease.  And we need to do everything we can to reduce risk there.  The risk is still to pregnant women; it’s not a broader risk.  But it is an enormous challenge in Puerto Rico.  We’re continuing to see women infected with Zika in Puerto Rico and we are very concerned about what the coming months will hold.

Ninth, the role of globalization and urbanization is crucial.  We have at least 40 million visits from the U.S. to places around the world where Zika is spreading.  We’re not going to stop the world because we want to get off.  Globalization and global travel has a lot of benefits in economic productivity, in interchange among people, in the ability to do what we do in the world.  But it does also have the inevitability of bringing risks closer to home.  A disease threat anywhere in the world may be just a plane ride away.  And the greater urbanization of the world is also facilitating outbreaks of Yellow Fever, in the Ebola epidemic.  It was the first time we had seen urban spread of Ebola which was enormously challenging to control.

Finally, I would like to say a word, tenth, about the remarkable innovations going on through CDC scientists, doctors, and other researchers.  We think of CDC as working with boots on the ground to protect you, and we are that.  We’ve also developed cutting edge technologies, virus-like particles and chimeric solutions that can knock down the spread of diseases spread like Zika by half, very simply, at a low cost.  And now we’re going to see if that can be implemented on a broad scale.  We’ve been working many years on a new class of insecticide that appears to be nontoxic, food grade, smells a little bit like grapefruit, and may be as effective as DEET.  So rapid cycle approaches in innovation are going to be crucially important to protecting ourselves, because the microbes are changing, and we need to adapt also.  We’re learning more each day.  We still don’t know what proportion of women who are infected with Zika will give birth to an infected child.  We don’t know what proportion of the infants born without microcephaly will have some impact later in life.  It may be months, years, or even decades before we know that.  We don’t know the risk factors of why certain women are more affected.  But we’re working very closely with Colombia, Brazil, Puerto Rico, and the U.S. to learn more.  The quicker we learn, the better we can protect American women.

In a public health emergency, speed is critical.  A day, a week, a month, can make all of the difference.  When Ebola was getting out of control in July of 2014, I said that we needed 300 Ebola beds in West Africa, a hundred in each country, and we needed them within 30 days.  It did not happen.  Within a few months, we needed 3,000 beds.  The fact that we can today potentially prevent dozens or hundreds or even thousands of deaths.  The experts tell me that in their 30 years of working on birth defects, they have not had a situation this urgent.  I want to particularly thank Dr. McCabe from the March of Dimes and his colleagues for all they’re doing to really make clear how extraordinarily unusual and urgent this situation is.  We now know that there are more than 300 women in the U.S., including territories, who have evidence of infection with Zika.  And that number will only increase.  We need to ensure that we have the resources needed to treat this emergency as it should be treated.  And if you just look at the definition of what an emergency is for a supplemental funding request, it has three categories.  It has to be unexpected.  This is not only unexpected, it’s completely unprecedented.  It has to be catastrophic.  And if you talk to any family of a child who has been born with a severe birth defect, there could be no better or more exact definition of a catastrophe.  It has to be permanent damage.  Sadly, damage to the developing brain is as permanent as anything.

When we began preparing the emergency supplemental request, there was a high level meeting that I was at.  And there was some discussion on what would be in it, how it would go, what we would do.  And I asked, well, how long is this going to take?  And they said, oh, it’s moving very quickly, probably three months.  And my jaw dropped, literally.  Three months in an epidemic is an eternity.

Zika threatens that too many parents will have to have the experience of not seeing their child grow to their full potential, graduate, get married, go to school.  And we need to make sure that all of us are doing everything in our power to minimize the number of families affected.  We’re not going to eliminate Zika in the near future.  It’s going to be a challenge.  But we can reduce risk.  We can protect women.  And to do that, government funding is essential.  Private funding is essential.  Philanthropic funding is essential.  Congress did the right thing with Ebola.  And I hope in the end, they will do the right thing with Zika.  They’ll do that without making us stop a battle in one part of the world to fight a battle in another part of the world.  You don’t stop fighting terrorism in the Middle East to fight terrorism in Africa.

One of the things that we had to do, because when we found out it would be at least three months for a supplemental, was to borrow money from other parts of CDC.  That includes emergency preparedness dollars that go out to Ed and all the other states to deal with things like leading the response, doing lab testing, tracking for outbreaks, responding to the health effects of natural disasters, dispensing countermeasures.  We had to take nearly $50 million of that money and put it to Zika.  The states weren’t happy about that.  But we had no choice.  We also had to take money that  was programmed for fighting Ebola in West Africa and use it temporarily, trusting that we’ll get it back from Congress, because we had no alternatives.  And Ebola is not over.  I’ll tell you that the most recent cluster emerged when a man who had survived Ebola 15 months earlier had sexual relations with a woman.  She developed Ebola as a result.  And she died.  Her family members died.  It ended up spreading to two countries.  We had five command and control centers.  We had to upgrade 50 health care facilities to they would be able to diagnose Ebola.  We identified over 1500 contacts, all emerging from one case.  We vaccinated 1,750 people.  We made 30,000 interactions with contacts to see if they were sick so they could be rapidly isolated and the outbreak wouldn’t spread.  And we were able to stop the outbreak.  But if we let down our guard, it could come roaring back.  And that same dynamic of letting it spread for a few days or weeks, and then it takes months or years to control, could have occurred.  We’re also with the funding that Congress provided for Ebola, making excellent progress on a critically important initiative called the Global Health Security Agenda.  This is about stopping outbreaks there so we don’t have to fight them here.

I was on the phone with my team in Uganda a few days ago, and really encouraged to hear the kind of things that’s going to.  They have had an outbreak of Yellow fever in Uganda.  A few years ago, they had an outbreak of Yellow fever, it spread widely, it killed a lot of people, and it was a huge problem.  Now they identified it quickly, they controlled it quickly, and they were even able to do whole genome sequencing and rapidly realize, it’s not related to the Angola outbreak.  So we’re in a new world of being able to find and stop threats where they first emerge.  And the better we do that, the safer we’ll be at home.  And that’s another part of the Ebola dollars that need to be protected.  We can’t be letting down our guard in one place to fight another battle.  We also need to make sure that there is enough money in a supplemental so that we can do the projects that are going to be hard but have to start now.  Understanding all of the effects of Zika on women and the infants who are born.  Developing better diagnostic tests so we can figure out if someone has been infected in the past.  Using our current tools in a mix and match way to figure out how we can knock down the mosquito enough to protect women and infants and developing new vector controls as well as a new vaccine.  None of these are easy.  None of them are going to be quick.  But the sooner we start, the sooner we can have an answer.

I also think that we have to be clear about what we can and can’t do about Zika.  At CDC, we always try to tell it like it is.  We don’t sugar over the truth.  We will tell you what we know, when we know it.  We’ll tell you what we don’t know and what we’re trying to do to find it out.  Within literally days of reviewing that slide that showed the Zika virus invading the fetal and also infant tissue, we issued the first travel advisory, on January 15th, saying that pregnant women should not travel to places where Zika is spreading.  I can’t tell you exactly how many pregnant women didn’t travel for that women.  I can total you that of the 300 women who we know of with Zika infection, the great majority traveled before that time.  So we believe that that public health action has prevented cases of Zika.  That means that babies whose names none of us will ever know will grow up healthy because we took the duty to warn seriously and did it promptly as soon as we had sufficient information to take public health action.  Now, it’s been pointed out that just in recent years, we’ve had H1N1, Ebola, Zika.  We’ve also had MRSA, H5N1.  We don’t know where the next health threat will come from.  We don’t know when it will come.  We don’t know what pathogen it will be.  But we are 100% certain there will be a next one.  And it’s our responsibility to be as ready as we possibly can be.  And the two key areas for that are the global health security agenda, building up the capacity of countries to find, stop, and prevent health threats, and putting in place an accountability framework so that the whole world can know which countries are ready, what they’re not ready for, and help for those countries that don’t have the resources.  It’s in all of our interests to help them build up those resources.  And for those who are providing the assistance to know if our assistance has actually been effective with an objective accountability framework.  And we also need to ensure that we can surge in when country capacity is overwhelmed.

At CDC, we’ve scraped together existing resources to create what we call the GRRT, the Global Rapid Response Team.  We currently have more than 300 staff rostered for this.  We have 50 people on call at any one time.  We’ve already deployed them at least five times to deal with Ebola, Zika, polio, Yellow fever.  And they’ve spent more than 600 days in the field helping out with local response.  So we’ve begun doing things.

But we lost time fighting Ebola, because we didn’t immediately move rapidly.  And I fear that we’re losing time with Zika, because we can’t move as rapidly as we would like to.  Congress did the right thing with Ebola.  I hope they will do the right thing with Zika, and they will do it soon.  There’s been talk that some of this should happen in the ‘17 process.  And this isn’t an either/or issue.  If the Senate bill doesn’t fully fund the administration request, if some of it were rolled into the ‘17 process that would be a good thing too.  We need to make sure we pay back the money we borrow and have the money to respond effectively.

Interestingly, I’ve been hearing  from both sides of the aisle, both houses of Congress, interested in thinking about news ways to do things, including having some form of public health disaster rapid response resource, it’s been sometimes called a FEMA for public health. It would need to cover both domestic and global.  It would need to have not only some resources available but authorities.  Authorities make a big difference.  There’s good reasons for the administrative procedures that we follow in the government.  But they don’t always match with emergencies.  In the Zika response, for example, we have been authorized to use what’s called direct hiring authority as a result, we have more than 70 people who have joined CDC to work full-time on this.  That makes a big difference.  One of our lessons, very internally, from Ebola is that we really wore our staff out.  We had 4,000 staff work on Ebola; 20 staff work in the Ebola unit in the regular time.  1400 people went to West Africa.  We didn’t have any serious injuries.  We didn’t have any Ebola infections.  But it was exhausting to staff.  We need to bring new staff on board.  Zika is not going to be a one month or one year program.  We need people working on it now who will be able to work on it long term.  There are administrative authorities as well as funding.  Kevin McCarthy in the House, Senator Dr.  Cassidy in the Senate, have both spoken about this issue.  I don’t know whether it will happen, how it will happen, but I do know that if we have money and mechanisms in advance, it minimizes the need for us to run to Congress for a supplemental and do something outside of the usual process.  It allows us to pull our focus where it should be on adapting rapidly to the response.

One of the key characteristics of responding to infectious disease threats is you have to adapt the response.  With Ebola, for example, we rapidly realized we could be a phased response when it was out of control.  We need to deal with safe and dignified burial first, better care next, then rigorous contact investigation and tracing.  That phased response allowed us to first break the back of the epidemic and then mop it up, clean it up, protect communities, and keep it in check.  There is the ability to change the shape of the epidemic curve in public health.  But the sooner you get there, the more dramatic impact you can make saving lives and ultimately reducing the cost.

Now, it is, as some have noticed, near the end of a second term of an administration.  I’ve had the incredible privilege to lead CDC for the past seven years.  That marks about 20 years I’ve been working at CDC, and I’m still learning about the great things that our dedicated staff do.  They continue to inspire me and to humble me with their sense of mission, their expertise, their creativity, their hard work, their intelligence.  CDC is a great buy for the federal dollar.  The taxpayers really get their money’s worth.  People work hard and are committed to what they do.  And we’ve made a lot of progress, not just stopping Ebola but in other areas as well.

And I thought, since I had given an earlier list of ten, I’ll give a list of ten things that we’ve done that have kept Americans safer and healthier.  One, we have made progress, and in all of these I would say not successes, but progress, because there is still more to do.  One, we’ve made progress reducing the number of health care associated infections.  One of the more serious of these, MRSA in infectious care units, has been cut in half.  Hospitals throughout the U.S., doctors, have improved practice.

Second, we’ve begun using whole genome sequencing, advanced molecular detection, to find and stop outbreaks faster.  This is exciting new technologies.  It allows you to trace the path of a pathogen in a way we never could before.  We did a proof of principle with listeria, sequencing every isolate in the country.  We got contaminated food off the shelf and today there are Americans alive who would have died if that hadn’t happened.  Went to Congress, they funded it, and Americans are live today because of their foresight in doing that.

Three, tobacco use.  Just announced this week, smoking is at an all-time low in the U.S.  15.1%.  Still a leading preventable cause of death, but millions of Americans don’t smoke who smoked just seven years ago.  The TIPS from former smokers campaign that CDC ran, the first ever national paid campaign against tobacco, has been incredibly effective.  It has helps about 400,000 Americans and helped change the conversation about smoking.  It has saved hundreds of millions of dollars in health care costs.  And the cost per life saved is a tiny fraction of what’s usually used as a benchmark.

Four, motor vehicle accidents or injuries, I should say, deaths, dropped sharply until 2013.  We have to look at more recent trends, which are concerning.  But motor vehicle crashes are an example of how we have to attack a problem from all angles, law enforcement, road design, industry, coming together can make driving much, much safer.

Five, teen pregnancy.  The lowest rate ever, down 42% since 2007.  All too often teen pregnancy perpetuates poverty in a community.  So the decline in teen pregnancy has many positive ramifications throughout society.

Six, HIV.  We’ve been promoting testing.  And now a greater proportion of people with HIV know they have it.  It used to be that only about one in five people living with HIV didn’t know they had it.  Now it’s about one in eight.  Progress.

Polio.  Number seven.  We’re closer to eradication than ever.  When I began, when we began the effort in 1988, there were 350,000 children disabled each year by polio.  Last year there were 74.  This year so far there have been 17.  When I began at CDC director, it didn’t look like we could get over the finish line in India.  We surged into India and we got to zero, India got to zero, incredible effort.  They put in a billion dollars to polio eradication.  Then we said, if India should do it, Nigeria should be able to do it.  We surged into Nigeria.  That polio eradication infrastructure in Nigeria stopped Ebola in Nigeria as well.  Now the challenge is Pakistan.  We’re close.  Whether it happens this year hangs in the balance.  But it can.

Eight, Haiti.  You don’t often hear Haiti and progress in the same sentence.  But little-known, since the earthquake we have indeed helped them build back better.  They have introduced new vaccines that will save more than 40,000 children’s lives.  And though you wouldn’t naturally think of the world elimination of a disease and Haiti in the same sentence, they’re on the path to eliminate three terrible diseases.  Malaria, which we think can be eliminated from the island of Haiti and Hispaniola, infant HIV, and filariasis, which is a terribly disabling condition.

Nine, PEPFAR.  A wonderful program started in the previous administration, continued and expanded in this administration is saving millions of lives around the world.  And CDC is honored to be a key implementer in that program.

And, ten, the global health security agenda, which I’ve already mentioned, where we have now more than 70 countries involved in making the world a safer place.

Imagine what CDC could do if we were fully funded.  How many earthquakes and hurricanes we could stop.  There are still major unfinished pieces of business.  And I’ll mention four of them.  Opiate overdose continues to be on the rise and is devastating families and communities.  Cardiovascular disease is still our leading killer.  And yet we could control it for very little money.  We should be able to do much better than we do preventing and treating high blood pressure and other leading causes of heart disease.  Three, antibiotic resistance. We risk being in a post antibiotic world.  That wouldn’t just be for infections that you think of as bad infections, pneumonia, urinary tract infections, that’s bad enough.  That could be for the 600,000 Americans a year who need cancer treatment for whom we just assume we’ll be able to treat infections.  We may lose that ability.

Just a few hours ago, the Department of Defense released information about a woman with no travel outside of the U.S. who is the first documented human case in the United States of having a urinary tract infection or any infection with an organism resistant to every antibiotic including the last one we had, Colistin.  It was an old antibiotic but it was the only one left for what I call nightmare bacteria, CRE.  What the Defense Department did at Walter Reed is they took organisms that were resistant — that had CRE that it had extended resistance, and they tested them for Colistin resistance.  In the first six they did, one was resistant.  This patient hadn’t traveled.  They had done just three weeks of testing.  We know now the more we look, the more we’ll find.  The more we look at drug resistance, the more concerned we are.  We need to do a very comprehensive job so we can have them and our children can have them.  We can make new ones, but without better stewardship and identification of outbreaks, we’ll lose these miracle drugs.  The medicine cabinet is empty for some patients.  It is the end of the road for antibiotics unless we act urgently.  Fourth, we need to do better as building and openly assessing rapid response capacity around the world.  Again, that global health security agenda.  Where countries aren’t prepared, we are at greater risk.  So the work is far from finished.

One thing that will bring us further along are connections.  Connections between the health care system and public health, between global and U.S. health, between the immediate needs and long term needs, between the public, nonprofit, and private sectors.  In all of those connections, what’s going to drive progress is the fundamental concept of accountability.  Never being afraid to ask how much difference are we making, are we succeeding, are we getting the results we need.  In the private sector, if you don’t, you don’t make a profit and you change your business model.  In the public sector, unless you have an accountability framework, you may not be able to correct what you’re doing to protect people well.  Now, I’m often asked how I feel as CDC Director dealing with things like Ebola and Zika.  And of course in the heat of the moment, you’re mostly concerned about getting the job done, concern about something or fear about something getting out of control, worry about being able to get the support, the inspiration of dealing with staff who are so focused on what they do.  But for me, when faced with emergencies like this, the greatest emotion has been frustration.

Imagine that you’re standing by and you see someone drowning, and you have the ability to stop them from drowning, but you can’t.  Now, multiply that by a thousand or 100,000.  That’s what it feels like, to know how to change the course of an epidemic and not be able to do it, for any reason, because of challenges in implementation or funding or administrative details, the challenges of working in partnership with other organizations.  Right now, the current crisis is Zika.  We need a robust response to protect American women and reduce to the greatest extent humanly possible the number of families affected.  We don’t know who those children will be.  We don’t know where they will grow up.  But anything we don’t do now, we will regret not having done later.  And if we don’t take this opportunity to learn the lessons and establish some sort of facility whereby we can respond immediately and surge in when there’s a problem, we won’t be fully prepared for the next emergency.  And we know there will be a next emergency.

Most of the times in public health, we do our work silently.  We’re in the background.  All of us are here healthier today, many of us are here alive today, because of things that public health did that we may not think about, whether it’s a vaccination or safe water or a safer environment.  Public health keeps us safe, healthy, and productive.  Now, imagine that you could stop an earthquake.  In public health, we have the ability to stop many of the health equivalents of earthquakes.  You have that ability, you in the media, you in philanthropic sector, you in public health, you in the corporate sector.  In fact, public health is everyone who protects the public health.  Thank you very much.  [applause]

Thomas Burr: Thank you, doctor.  Got a lot of questions.  We’ll try to get through these as quickly as possible.  I wanted to follow up on something you said as you started to speak.  You said that the microbes are changing.  Is there a concern that the Zika virus is mutating in ways that will make it even more concerning than it already is?

Dr. Tom Frieden: We don’t understand why we’re seeing this with Zika for the first time.  There are at least four possibilities.  Maybe the virus changed.  We’ve looked at the genome, it hasn’t changed much, but we don’t understand the genome fully, so even a small change could result in it.  It may be that it was happening in Africa for years and we weren’t looking so we didn’t realize it.  It may be that it was so rare that it didn’t occur often.  Or it may be that it was so common that women were infected before childbearing and therefore you didn’t see it.  So we just don’t know.  These are some of the things we need to find out going forward.

Thomas Burr: Given the forecast for a fairly hot summer, and as you might have seen, a lot of recent rain, what are your current expectations for how many pregnant women in the United States might get Zika this year, and how many Zika-related cases of fetal defects might we see in the U.S.?

Dr. Tom Frieden: For Zika, we will look at how two other viruses, dengue and chikungunya, are spreading.  They are spread by the same mosquito. So we can’t guarantee that Zika will behave as those two viruses have behaved, but if it does we would expect to see several different patterns.  First, Zika associated with travel virtually everywhere.  We’ve already had more than 500 such cases in the continental U.S. Those are generally symptomatic cases, so many more infections that we haven’t recognized.  There are 40 million visitors so you do expect a lot of travel-associated cases.  In Puerto Rico and the U.S. territories, where dengue and chikungunya spread very rapidly, unfortunately the likelihood is that within a year we will see hundreds of thousands of infections.  So that is a real concern.  In other parts of the U.S., including Hawaii, we’ve seen yet a different pattern of Zika spreading — I’m sorry, the dengue spreading.  If Zika spreads that way, it could spread for months and be very difficult to control but at a very low level.  In parts of the southern U.S. like Florida and Texas, we’ve seen clusters of dengue and chikungunya.  In the past, they have not been widespread.  They have been quite focal.  And the local governments, local areas have been very effective at doing mosquito control to prevent widespread transmission.  That is the most likely scenario in terms of Zika.  We do expect there will be some spread through mosquitoes in some parts of the continental U.S. We do work very closely with the state and local entities there to try to keep that to the absolute minimum.  That’s one reason we need robust resources so we can ensure that we are doing everything in our power to minimize the risks to American women.

Thomas Burr: Still on the scope of the academic, there doesn’t seem to be much news, if any, but Zika infected people in Europe or even Asia or Africa.  Could you please help me understand what’s going on there?

Dr. Tom Frieden: We have seen, for example, sexually transmitted Zika in parts of Europe.  We’re really not sure what’s happening in Asia.  It may be that Zika has been around for so long that people are immune to it.  Or it may be they’re going to have a large outbreak.  Only time will tell.  That’s one reason we need really good monitoring systems in place to track what’s happening.  When we improve monitoring systems, it’s like civil aviation.  If the whole world does it together, the whole world is safer.  That’s one thing that we have to continue to strengthen in global health.

Thomas Burr: There’s a large event happening in Brazil this summer.  If you were in charge of this year’s summer Olympics, what would you do?  Would you cancel it?  Would you move it to a safer place, postpone it?

Dr. Tom Frieden: There is no public health reason to cancel or delay the Olympics.  Our recommendations from CDC about travel is a recommendation regardless of why you travel.  We say, if you’re pregnant, don’t go somewhere where Zika is spreading.  If you have to go to somewhere where Zika is spreading and you’re pregnant, be really careful about mosquito bites. If you’re a male in a place where Zika is spreading and your partner is pregnant, use a condom.  The risk to delegations going and to athletes is not zero.  The risk of any travel isn’t zero.  But the risk isn’t particularly high, other than for pregnant women.  And some have said, well so much travel to the Olympics – that may spread the disease. We’ve look at this.  Travel to the Olympics would represent less than one quarter of 1% of all travel to Zika-affected areas.  Even if you were to say the Olympics weren’t to happen, you would still be left with 99.75% of the risk of Zika continuing to spread.  The fact is, we are all connected by the air we breathe, the water we drink, the food we eat, and the planes we ride on.  It is a world where interconnection is the new normal.  And rather than try to stop the world because we want to get off, let’s take steps to make as much of the world as safe as possible for all of our sake.

Thomas Burr: thank you, sir.  From what i understand, it seems there are only six states in the united states that are still Zika-free, having not reported any cases.  Alaska, Idaho, North Dakota, South Dakota, Washington, and Wyoming.  What do those states have that the others lack?

Dr. Tom Frieden: Fewer travelers from Zika-affected areas.  And just a matter of time before they also have some cases, i think.

Thomas Burr: Let’s get to funding for a second.  Have you been prevented from doing anything as a result of Congress not yet acting on emergency funds for Zika?

Dr. Tom Frieden: We’ve been able to get a start on things that are needed immediately for the Zika response.  What we haven’t been able to get started on are some of the longer term projects that we have to start now that are going to take time.  There’s the old saying, the best time to plant a tree is 20 years ago.  The second best time is today. We haven’t been able to plant those trees, we haven’t been able to begin the really important work to come up with better diagnostics, to come up with better mosquito control strategies, to do that in the robust way that we’re going to need.

Thomas Burr: Thank you.  So keeping on the funding for a second, how do you respond to claims, especially by many congressional republicans, that the administration’s $1.9 billion request is vague, incomplete, or could result in a blank check or as some called it, a slush fund?

Dr. Tom Frieden:  For the CDC component of the administration request, it was $828 million.  We have a line item.  It is our best, most honest estimate of what we need to fight the epidemic.  And it may be under for some areas, where the drug resistance results came back, insecticide resistance results came back, some of the alternative insecticides cost two or three times as much, so we might need more than that.  If other communities do things in certain ways, we might need less than that.  But that’s our best estimate for what we need for CDC.  The Senate compromise bipartisan proposal funds nearly all of what CDC requested and would allow us to have a really great start.  And really, the two things that are key are: please reimburse the money we borrowed because it’s still needed to fight emergencies including in the U.S. and overseas, and second, make sure we have enough resources and authorities to protect women as effectively as we possibly can.

Thomas Burr: Still on funding for a second, other than the public health emergency preparedness fund, what specific programs has the CDC had to cut in order to pay for Zika?

Dr. Tom Frieden: Well, there are a couple of things that are going on.  One, as you mentioned, we took $50 million from the Public Health Emergency Preparedness Program, not because we don’t like that program, it’s important.  It was the only place we could go where we are allowed by congress to redirect 10% of it. So we took 10% it and put it towards Zika.  That meant that states like Ed’s are getting less money.  And they have to deal with: Can they pay their staff that are doing emergency preparedness? Can they respond to outbreaks? Can they track systems?  That’s one piece that we very much hope will get restored.  The second that we used at CDC, we had some dollars that were programmed to fight Ebola in Liberia, Sierra Leone, and Guinea, in ’17 and ’18, because it’s five-year money.  So we said we have nowhere else to go, so we’re going to take the money from there but we need it back so we can prevent Ebola from coming roaring back.

Thomas Burr:  Let’s talk about prevention here.  What’s your view on the use of mosquito repellants with DEET especially by pregnant women?  Are there other side effects of using DEET? And what mosquito repellants would you actually recommend?

Dr. Tom Frieden:  DEET when used as directed is effective and safe, including in pregnancy.  One of the things we’ve done in Puerto Rico, with support from some of the companies that are here, is to distribute Zika prevention kits or ZPKs.  We’re already distributed 10,000 of them.  There are about 32,000 pregnancies in Puerto Rico per year.  So we’re getting close to reaching a large proportion of at-risk women and we’re finding great interest.  The challenge is not so much are they safe? But are they effective? Because you’ve got to apply multiple times of the day, you have to apply indoor and outdoor.  We’re looking at a comprehensive program that deals with screens and killing larvae and getting rid of breeding sites, killing adult mosquitoes.  It’s what I call, the four corners approach, inside, outside, adult mosquitoes and larval mosquitoes.  We have some new tools that are very exciting.  One I mentioned earlier, the autocidal gravid ovitrap (AGO) trap, which kills female gravid mosquitoes. There are some other products that the EPA has rapidly approved which we would like to get into field trials in Puerto Rico over the next few weeks.  The challenge is there’s no magic bullet to get rid of this mosquito.  It’s really tough.  And we need to try a comprehensive approach, drawing together the different tools that we have and figure out what works.

Thomas Burr: What’s the timeline, is there a timeline for a vaccine for genetically modified mosquitoes, for an effective anti-Zika viral drug?

Dr. Tom Frieden: I think for all of these research priorities, you have to, one, go full steam ahead in developing them, seeing if they work, but two, not assume they’re going to be here and be here soon.  So the most promising is a vaccine.  Immunity to Zika appears to be long-lasting and potentially lifelong.  So in theory, making a vaccine against it should work.  And the vaccines that are being tried are killed vaccines, they’re not going to result in an infection.  Initially we weren’t quite sure if the microcephaly caused by Zika might be an immune response, in which case the vaccine would have the potential to make it not be protective.  But now it’s very clear that it’s a direct virus attack.  So a vaccine could work, should work.  But it’s going to be at least a year or two before we know if it’s safe and effective.  And that’s often optimistic in terms of vaccines.  NIH is doing terrific work.  They’ve got five different potential vaccines candidates.  They expect to be in phase one trials in September, phase two trials beginning early next year, and depending on how those go, we could have a vaccine in the next couple of years.  But we can’t count on it.  And even if we do, we’re still going to have other mosquito-borne diseases.  So we still need new classes of insecticide.  We still need new ways to control this mosquito.

Thomas Burr: You talk about repellants and insecticide.  Aren’t there other health effects of using those as well?

Dr. Tom Frieden:  So it’s very important to use any product safely.  And whether it’s insecticides, repellants, larvicides, pesticides that kill adult mosquitoes, there has been important technological advancement in recent years.  We now know more about ultra-low volume spraying, about the particle size that’s most effective for mosquitoes, and will minimize toxicity, about how to apply and where to apply.  There are parts of the U.S. that are doing really excellent work on this.  And we’re all learning from them.  So there are technological advances.  There is nothing that is risk-free in life.  So it’s always going to be a balancing act.  But applying things effectively is going to be a way of minimizing risk, especially in a place that has a high risk in Puerto Rico.  I think you’ll find in any community that there are some people who want more spraying and some people who want less spraying.  So part of that is a community discussion.  And part of that is trying to get the facts out there of what are the potential risks and what are the potential benefits.

Thomas Burr: You just talked about Puerto Rico.  What has the impact of the debt crisis there had on fighting this?

Dr. Tom Frieden:  It hasn’t made it easier.  Puerto Rico is faced with a very challenging situation, not just economic and political, but also in the health care context.  Their Medicaid program has deep problems and is unable to pay physicians.  One of the things the CDC Foundation is working on is a way to reimburse physicians for the care they provide for women who choose not to become pregnant during this time.  It’s making an incredibly difficult situation even harder.

Thomas Burr: What level of confidence do you have that the virus persists in blood and semen for weeks and/or months and/or years?

Dr. Tom Frieden: There are a few things that we know.  Virus persists in blood for only about a week.  It persists in urine for about two weeks.  It persists in saliva for about a week.  That’s been studied.  Semen is an unknown.  There have been reports of virus persisting, not necessarily live virus but at least parts of virus, for up to two months.  We’ve seen long persistence in Ebola.  Those studies need to be done, those take six to 12 months to do, at best, and we still may not know of the outlier situation, where there may be someone who has a different course of infection as occurred with the recent Ebola cluster in West Africa.  So, we have to recognize there are many things we don’t know in Zika.  We give the best available advice based on the most recent and best available information.

Thomas Burr: Could you have Zika not develop symptoms, should anyone who has been in a risk zone get tested?

Dr. Tom Frieden:  About four out of five people infected with Zika we believe don’t recognize any symptoms.  The challenge with testing, is we don’t have widespread, widely available testing for past infection.  In fact, the past two or three months, we don’t have any testing to see if you’ve been infected.  We need industry to come to the table and develop new tests.  We need basic science to develop tests.  They’re not easy.  This is not an administrative or operational problem.  This is a scientific problem that is very, very difficult to do.  There have been efforts to do this for many years that haven’t been successful. So we have scientific challenges and that’s also one of the areas that we want to begin that long term work, the sooner we begin that long term work, the sooner we’ll have answers.

Thomas Burr: Thank you.  Before I ask the last question, the National Press Club is the world’s leading professional organization for journalists and we fight for a free press worldwide.  For more information about the Press Club, please visit our website at press.org.  I would also like to remind you about some upcoming programs.  On June 13, Girl Scouts of the USA CEO will speak at the Press Club luncheon.  On June 20, the Federal Communications chairman, Tom Wheeler.  Michael Middleton, University of Missouri’s interim president, will speak here the next day.  The next day, June 22nd, labor secretary Tom Perez will cap off what for me will be a 40-hour 3 day workweek.  I would like to present our guests with the National Press Club mug.  This is your fourth visit, I believe, so you now have a full set.

Dr. Tom Frieden: Thank you.  [applause]

Thomas Burr:  For my last question, sir, your job is to protect the health of Americans, but we all have our vices.  So my question is, what is your guilty pleasure?  Netflix, chocolate?

Dr. Tom Frieden: Well, desserts, I have to say.  I love sweets.  And it’s okay to like things that are unhealthy.  Everything in moderation, including moderation.  Sometimes people think that public health is about telling people not to do things that are fun.  But actually, I would rather think of public health as helping people identify the sweet spot, identify things that you love doing, whether it’s walking or dancing or walking the dog or playing basketball, that are healthy and help you to live a longer, healthier life.  We’re about empowering.  Empowering means that if you go about your business, you don’t have to worry about getting killed by a resistant bacteria or having a child with a terrible birth defect.  Public health is about helping all of us live healthier when we just go about our business and do what we want to do.  Thank you all very much.  [applause]

Thomas Burr:  Thank you.  We are adjourned.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES