Assessment of State, Local, and Territorial Zika Planning and Preparedness Activities

United States, June 2016-July 2017

Bhavini Patel Murthy, MD; Sara Vagi, PhD; Rodel Desamu-Thorpe, MD; Rachel Avchen, PhD


Morbidity and Mortality Weekly Report. 2018;67(35):969-973. 

In This Article

Abstract and Introduction


The emergency response to Zika virus disease required coordinated efforts and heightened collaboration among federal, state, local, and territorial public health jurisdictions. CDC activated its Emergency Operations Center on January 21, 2016, with seven task forces to support the national response. The State Coordination Task Force, which functions as a liaison between jurisdictions and federal operations during a response, coordinated the development of CDC Guidelines for Development of State and Local Risk-based Zika Action Plans, which included a Zika Preparedness Checklist.[1] The checklist summarized recommendations covering topics from the seven task forces. In July 2016, CDC's Office of Public Health Preparedness and Response (OPHPR) awarded $25 million in supplemental funding to 53 jurisdictions (41 states, eight territories, and four metropolitan areas) to support Zika preparedness and response activities. In December 2016, CDC awarded an additional $25 million to 21 of the 53 jurisdictions at the greatest risk for seeing Zika in their communities based on the presence of the mosquito responsible for spreading Zika, history of local transmission, or a high volume of travelers from Zika-affected areas. The additional $25 million was part of the $350 million in Zika supplemental funding provided to CDC by Congress in 2016*.[2,3] Funded jurisdictions reported progress through the checklist at five quarterly points throughout the response. Data were analyzed to assess planning and response activities. Among the 53 jurisdictions, the percentage that reported having a Zika virus readiness, response, and recovery plan increased from 26% in June 2016 to 64% in July 2017. Overall, Zika planning and response activities increased among jurisdictions from June 2016 to July 2017. The recent Zika virus outbreak underscores the importance of strengthening state, local, and territorial health department capacity for rapid response to emerging threats.

Jurisdictions selected to receive supplemental funding for Zika preparedness and response were chosen based on the estimated geographic range of the two mosquito vectors known to carry and likely transmit Zika virus (i.e., Aedes albopictus and Aedes aegypti) in the United States in 2016.[3] Funded jurisdictions included 41 states, eight territories (American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Palau, Puerto Rico, and U.S. Virgin Islands) and four local jurisdictions (Chicago, Los Angeles County, New York City, and the District of Columbia).§ In April 2016, the Zika Preparedness Guidance document, based on the CDC guidelines,[1] was distributed from the State Coordination Task Force to state, local, and territorial health departments preparing to respond to potential Zika virus transmission; funded jurisdictions were required to complete the checklist. Health department staff members were expected to address elements in the CDC guidelines, and they were required to submit quarterly progress on the checklist based on whether they 1) had fully completed the actions listed; 2) had begun the actions, but had not fully implemented or completed the actions; 3) had not started the actions; or 4) did not answer because the guidance element was not applicable to their jurisdiction. Data were collected at baseline in June 2016 and at the end of each quarter in October 2016, January 2017, April 2017, and July 2017.

The checklist divided the Zika response into four phases to reflect the burden and intensity of risk for Zika virus transmission. The pre-incident stage included phase 0 (preparedness) and phase 1 (mosquito season, but no local transmission). Phase 2 was defined by confirmed local transmission, and phase 3 by confirmed local multiperson transmission. Respondents completed up to 112 questions depending on the presence of capable vectors and the extent of local transmission. Questions were aggregated within the following seven activity domains: 1) operations and planning, 2) communications and community education, 3) vector control, 4) surveillance, 5) laboratory testing, 6) outreach to pregnant women, and 7) blood safety. For each reporting period, the number and percentage of jurisdictions reporting activity on ≥85% of the guidance elements (selected as the minimum indicator of Zika preparedness) was determined.

Jurisdictions with multiple confirmed cases of local mosquitoborne transmission of Zika virus increased from three in June 2016 to seven in July 2017 (Table 1). By October 2016, all jurisdictions were reporting cases (mostly travel-related, except in the territories, where endemic transmission was occurring) during their respective mosquito seasons and provided responses to all guidance elements through phase 1. Ten jurisdictions provided responses for elements in phases 2 and 3.

During phases 0 and 1, the percentage of 53 jurisdictions reporting activity on ≥85% of the guidance elements ranged from 77% (operations and planning) to 98% (communications and community education and outreach to pregnant women) (Table 2). During phases 2 and 3, the percentage of 10 jurisdictions reporting activity on ≥85% of the guidance elements ranged from 71% (vector control and outreach to pregnant women) to 100% (operations and planning, surveillance, laboratory testing, and blood safety).

Jurisdictions reporting development of Zika virus readiness, response, and recovery plans increased from 14 (26%) in June 2016 to 34 (64%) in July 2017 (Table 3). There was an increase in the number of jurisdictions reporting updated training and educational materials for pregnant women (outreach to pregnant women domain; from 24 [45%] to 46 [87%]), publicizing travel guidance (communications and community education domain; from 31 [58%] to 51 [96%]), and developing state action plan for vector control (vector control domain; from 17 [32%] to 30 [57%]).

Among the seven jurisdictions experiencing local transmission in July 2017 (American Samoa, Florida, Federated States of Micronesia, Puerto Rico, Marshall Islands, Texas, and the U.S. Virgin Islands), five monitored effectiveness of vector control treatments through trapping and re-treating if mosquito numbers began to increase again (vector control), and five had laboratory testing staff members and surge reagents in place (laboratory testing). Similarly, six of the seven jurisdictions developed community outreach plans to prevent sexual transmission (communications and community education), expanded vector control efforts within areas of local transmission (vector control), expanded surveillance and monitoring of pregnant women (surveillance), developed procedures to follow up with Zika positive blood donors (blood safety), and identified geographic areas for aggressive response efforts (operations and planning).

* The other funds were distributed for Zika efforts via other means. For example, CDC awarded nearly $97 million to 58 state, territorial, city, and local public health departments through the Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement; $8 million to 38 state, territorial, and local jurisdictions for Zika birth defects surveillance activities; $40 million to four universities to establish vectorborne disease regional centers of excellence; and $14 million to the Puerto Rico Science, Technology, and Research Trust to oversee the first vector control unit in Puerto Rico.;
Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia, and Wisconsin.
§ Other jurisdictions, including nine states, not receiving funding were not asked to provide any information on the checklist or progress on Zika-related activities. Although these other jurisdictions did not have mosquitoes capable of transmitting Zika virus and therefore were not selected to receive the supplemental funding, cases of Zika acquired during travel could be identified in any location.