The Associate Collective Special Zika Issue 2017 For associates, By associates

Inside This Issue

  1. Introductions
  2. Puerto Rico Deployments
  3. Atlanta Deployments
  4. Field Assignments
  5. Utah’s Zika Virus Case Investigation and Response

This issue of the Associate Collective is brought to you by:

  • Kim Tran, Outgoing Editor-in-Chief
  • Corinne Thornton, Outgoing Team Coordinator
  • Emily Weno, Incoming Editor-in-Chief
  • Maria Dionicio Bernabe, Incoming Team Coordinator
  • Jeffrey Ramos-Kuilan, Special Contributor
  • Hope Tranberg, Special Contributor
  • Henry Olano-Soler, Class of 2015 SEW Representative
  • Bria Hamlet, Outgoing LC Liaison
  • Shannon Macika, Incoming LC Liaison
  • The PHAP LC Executive Board
  • And associates who have been deployed!


This issue of the Associate Collective was created to highlight the work of the Public Health Associates who supported the Zika response from 2016 to 2017. Nearly 60 associates from the 2014 and 2015 classes were deployed to Puerto Rico, Atlanta, and other field locations.

Skilled Associates Ready to Go

Public Health Associates are not limited by the scope of their assignments and the training nature of the PHAP. Each associate brings unique and diverse background experiences and skills that can contribute to the agency and the public in the time of a public health emergency. The Zika response was no exception, as associates proved to be prepared to rise to the challenge to protect the health and well-being of people during one of the most complex epidemics to ever affect this hemisphere.

Puerto Rico Deployments

A Message from the PR Chief of Staff:

“The Puerto Rico Department of Health’s Zika Response would like to express its sincerest gratitude for the support the Public Health Associate Program has provided. These young professionals have been instrumental within our response, undertaking critical roles in operations, partnerships, data entry, community outreach and many other key areas. We would not have achieved the profound accomplishments and results during this arduous year without their assistance.”

Dr. Dana Thomas, PR Zika Response Chief of Staff

Stories from Associates Deployed to PR

Left to right, Back to front: Olivia Stone, Shaakira Jones, Monet Goudrealt, Hillary Golden, Melissa Arias, Karla Marrero, Omolola Olaeye Jillian Newsman, Henry Olano-Soler, Taylor Watson, Jeffrey Ramos-Kuilan, Dr. Dana Thomas

Associates Assigned: Jeffrey Ramos-Kuilan


Role: Jeffrey provided overall response direction, management and coordination for all operational functions of the EOC. He established operational priorities and strategies along with the Incident Manager and the Chief of Staff. He coordinated to ensure effective field incident response and the management of operational resources. He provided senior operational representation when M&O Coordinator is not available and managed all operations directly applicable to the response mission. He led Operations team ensuring safety and welfare of all deployed and contracted personnel. He determined needs and requested additional resources when required. He reviewed requests for resources before they were released. He Reported information about special activities, events, and occurrences.

"Every day I had to face multiple challenges and after weeks of OJT, I had to take multiple decisions on a daily basis. Most of the time I was the only leadership position present at the EOC, who over 11 teams depended on. I was able to develop as an unusual PHAP and leader at multiple levels and I had the opportunity to meet, brief, and work along multiple CDC and PRDH senior leaders. I also had the unique opportunity to be the moderator at an Incident Manager’s meeting with Dr. Frieden as the VIP guest." -Jeffery Ramos-Kulian
Jeffrey (left) wishing a good farewell to the staffing Coordinators in Puerto Rico, Lourdes (Mariana) Ponte and Bianca Alba.

Associates Assigned: Bianca Alba, Mariana Lourdes Ponte-Cordova, Rachel Browning


Role: The staffing coordinator is tasked with managing staffing needs and developing deployments processes. Although keeping track of deployment needs and adapting to constant changes in protocols is a challenge, the Puerto Rico EOC and the Atlanta CDC EOC teams are very helpful and readily respond to all staffing requests.

"Being deployed in Puerto Rico hit close to home -- because I am Latina. Being able to speak my native language in a work environment where not only was it appreciated but needed made this experience more than just rewarding. In the couple months I was deployed not only did I gain a second family but I realized a new definition of hard work, sacrifice, and commitment." - Bianca Alba
A weekend in Mosquito Bay in Vieques, PR. From left to right: Dr. Harris (PR Vector Control Unit Lead), Mariana Ponte (incoming Staffing Coordinator), Adrienne G. (Unified Coordination Group team member) and Bianca Alba (outgoing Staffing Coordinator)
"Another thing that I cherished from this experience was volunteering to deliver Zika Prevention Kits to the WIC clinics. This experience was enriching as I was able to see first-hand how Zika has affected different communities and what barriers exist with engaging pregnant women." -Rachel Browning
Left picture: Bridget Richards and Bianca Alba in a community outreach event in Hatillo Puerto Rico. | Right picture: From left to right, top to bottom--Bianca Alba (Staffing Coordinator), Emma Quero (PR EOC Lead), Mary Ellen (Mel) Fernandez (PR EOC Management & Operations Coordinator), Marianna Ponte (Staffing Coordinator), Jeffrey Ramos (PR EOC Deputy Management & Operations Coordinator), Ana Mercado (PRDH PR EOC Planning Chief), Damaris Diaz (PRDH PR EOC Deputy Planning Chief) at the PRDH EOC-Multiagency Coordination Center.

Associates Assigned: Rasheedat Akin-Adrijo, Jacqueline Crain, Lindsay Engh, Sabrina Hansen, Kaamana Mirchandami, Cameron Warner, Melissa Arias, Kaitlyn Ciampaglio, Naomi David, Hodan Eyow, Katherine Ficalora, Nicole Frager, Hilary Golden, Monet Goudreault, James Guest, Shaakira Jones, Lauren Marsh, Keegan McCaffrey, Tyler Means, Jillian Newsam, Omolola Olaeye, Cory Portner, Folasuyi Richardson, Emmanuel Rodriguez, Tracy Semcer, Amy Smart, Shakina Wright, Theresa Yu, Mackenzie Zendt


Role: Data entry associates performed data entry from Arboviral Case Investigation Forms (PRDH Zika specimen submission form). The ACIF is a comprehensive laboratory and surveillance data form used to process Zika virus specimens. One challenge that associates faced was that forms are completed in Spanish and 98% of them are handwritten, which makes them hard to understand.

Kaitlyn Ciampaglio working at Dengue Branch in Puerto Rico. She spent a large majority of her deployment working with Arbovirus Case Investigation Forms (ACIFs) that were linked to specimens being tested for Zika. These forms contained valuable information which included patient demographics, symptoms, and provider information. Kaitlyn was able to link infant specimens to their Zika positive mother’s specimens, in order to allow a more efficient postnatal follow up and surveillance process.
“One of the best parts of being deployed to Puerto Rico last July was seeing this complexity in action. Our job was to enter clinical case data but we got to work with dedicated CDC staff tackling birth defects, Guillain–Barré syndrome, vector control, epidemiology, and disease modeling- and those were just the groups working in our trailer at the CDC Dengue Branch." -Keegan McCaffrey
Left: Kaitlyn Ciampaglio, Laura Adams, and Eduardo Rivera took this picture during Dengue Branch’s Hispanic Heritage Month Celebration. Although everyone was busy working around the clock during the Zika Response, it’s always necessary to take time to recognize culture, heritage, and the importance of food! Kaitlyn took part in the celebration by helping Eduardo make tostones (fried plantains). | Right: Mitchelle Flores, Aidsa Rivera, Kaitlyn Ciampaglio, Laura Adams. These women taught Kaitlyn about a variety of things while she was deployed – everything from epidemiology to Puerto Rican culture! These women were not only Kaitlyn’s supervisors, but eventually became mentors and friends.

Associate Assigned: Roberto Henry

POSITION: Incident Manager's Operations Coordinator

Roberto shakes hands with CDC Director Dr. Tom Frieden while acting as his on-the-ground control officer in Puerto Rico.

Roberto's Role: Roberto was deployed for 60 days to CDC’s Zika virus response in Puerto Rico, where he served as the incident manager’s operations coordinator, supporting the incident manager with her day-to-day activities, including maintaining her schedule, taking meeting minutes, tracking action items, and serving as a liaison to the local emergency operations center. He also provided on-the-ground logistics support for CDC Director Dr. Tom Frieden and his team during one of the director’s visits to Puerto Rico during the response.

Atlanta Deployments

From CDC clearance coordination and email triage to prepping for meetings with leadership and compiling reports, the associates deployed to the Emergency Operations Center at the CDC headquarters in Atlanta were crucial in assisting the Zika response teams and task forces in a fast-paced, 24/7 environment. Their help enabled multi-agency coordination, research, and addressing the public’s response to operate more smoothly and efficiently.

Stories from Associates Deployed to Atlanta

Associate Assigned: Arielle Arzu


Role: Arielle Arzu acted as Special Assistant to assist the Team Lead and Deputy Team Lead. She compiled documents, information, and resources when required; researched and compiled responses for external/internal inquiries; prepared high-level reports as needed; coordinated special projects; triaged e-mails to the appropriate staff/team ensuring efficient communication and timely response; and routinely briefed the task force leadership on status of tasks.

“I planned, scheduled, and coordinated activities for the December 5th 2016 Florida and CDC Zika strategy-planning meeting that includes hosting congressional member and CDC Subject Matter Experts. This meeting allowed leaders to reflect on lessons learned during the winter season and create recommendations for 2017. [I also] created an executive summary for the December 5th Florida and Zika Congressional and Subject Matter Expert Planning meeting that concluded in suggested recommendations to relieve the burden of Zika in the state of Florida for 2017. Members of this closed meeting included Dr. Frieden, Miami-Dade Mayor, Miami-Beach Mayor, and the Secretary of Health." -Arielle Arzu
Arielle Arzu with the Medical Investigation Team busy at work.

Associates Assigned: Tiffany Bazzelle, Demitrius Edwards, Lauren Ho, Holley Hooks, Angela Medina, Kira Mori, Alexandra Moore, Jordan Schultz, Corinne Thornton


Role: The primary function of IM Support was to provide operational support to the leadership team comprised of the Incident Manager (IM), Deputy Incident Managers, and Response Management Officer of the Zika Virus Response.

Front row to back, right to left: Aldo Davila (Puerto Rico Coordinator), Anne Sowell (Associate Director of Science), Melissa Edmiston, (Deputy Response Management Officer), Mardi Ithier (Incident Management Assistant), Angela Medina (PHAP), Wendy Buckley (Deputy Incident Management Ops Coordinator), Paul Smith (Response Management Officer), Brett Peterson (Deputy Incident Manager), Denise Jamieson (Incident Manager), Catherine Couper-Espinosa (Deputy Response Management Officer), Tiffany A. Bazzelle (PHAP)
At the EOC. Left to right: Jordan Schultz, Lauren Ho, Dr. Tom Frieden, and Kira Mori
“I specifically facilitated subject matter expert (SME) task force meetings, captured and reported IM priorities weekly via the IM Progress Report, and streamlined two reporting systems to create the re-designed Vital Information Report (VIR). The VIR briefs CDC leaders, HHS leadership, and other key stakeholders on response outcomes and pertinent information. I also had the opportunity to organize the Emergency Response Journal Club, hosting 5 leading SMEs in Zika.” - Tiffany Bazzelle
Angela Medina (left) and Tiffany Bazzelle (right) celebrating the holidays at work.
Demetrius Edwards and Dr. Tom Frieden during his farewell engagement.
"I was responsible for guiding scientific documents (e.g. manuscripts, guidance, MMWRs) through the eClearance database. I worked closely with the Joint Information Center (JIC) and Deputy Incident Managers to ensure documents were moved through the system expeditiously and contained accurate information. Also, I was responsible for revising briefing slides for two executive meetings, the Director’s Update Brief (DUB) and the Incident Management Update Meeting. The DUB is a one hour in-person bi-weekly meeting where SMEs presented relevant findings to CDC and IMS leadership. The IM Update is weekly and allows task-force leads to share information about their activities IM leadership." -Demetrius Edwards
From left to right: Angela Medina (IMS), Holley Hooks (IMS), Dr. Frieden, Corinne Thornton (IMS), Tiffany Bazzelle (IMS), Mike Metclaf (Epi Team).

Associates Assigned: Hayley Mandeville and Carissa Sera-Josef


Role: Z-BET is the first of its kind as it marks the first time the CDC assembled an agency-wide team as part of an emergency response. The mission of Z-BET was to ensure that budget execution activities were completed quickly, making it easier for teams and task forces to obligate their budgeted funds.

Carissa Sera Josef (left) and Hayley Mandeville (right) holding the Z-BET Desk Manual.

Hayley Mandeville was mainly responsible for critical components of Z-BET: staffing and internal documents and processes. For one, she elevated and maintained all staffing forecasts and internal processing documents. These documents are vital in strategic planning and ensuring Z-BET is fully staffed at all times with individuals who can provide expert care to the CDC Emergency Response Teams. Additionally, Hayley developed a documentation format to illustrate Z-BET’s accomplishments in staffing and tracking efforts. This document will be utilized in planning for future responses as it demonstrates the purpose and work load of a team like Z-BET in an emergency response. Lastly, Hayley performed the Master Tracker duties when needed.

"As someone who aspires to a career in healthcare administration, I was excited to be a part of the strategic planning processes of an ever-changing team adapting to the needs of the response.” -Hayley Mandeville

As part of Z-BET, Carissa Sera-Josef worked alongside leadership to enhance and maintain the Master Tracker- a large document used to track the status of all procurement actions for the Zika Virus Response, as well at the overall $350 million budget. Carissa also enhanced data visualization of the Master Tracker for leadership by developing several graphs and charts. Maintaining the tracker and synthesizing the data were critical in order for leadership to track the progress of the response funding. Carissa also assisted with staffing duties for Z-BET and the Global Migration Task Force when needed.

“As part of the Zika Budget Execution Team, I was able to experience the logistical side of the response by tracking all of the procurement actions for 12 teams and task forces using Zika funding. The experience helped me gain a greater understanding of the numerous moving parts of the response and an appreciation for all of the individuals coming together to reach a common goal.” -Carissa Sera-Josef

Carissa and Hayley were also tasked with completing a “Leadership Project” that identified an issue or a challenge and proposed a solution. After a couple of weeks on the job, they both realized they had pages and pages of valuable notes that they felt could be compiled into a Z-BET Desk Manual which would act as a Standard Operating Procedure (SOP) for new Z-BET members. The desk manual ended up being 56 pages and counting considering it is a living document and will be updated along the way.

At Dr. Frieden’s farewell banquet from left to right: Hayley Mandeville (Budget), Alexandra Moore (IMS), Dr. Frieden, Hope Tranberg (Epi Team), Carissa Sera Josef (Budget).

Associates Assigned: Jannae Parrott


Role: The evaluation team data analyst had to create survey questions, collect, clean, analyze and visualize the data, and report findings to the Evaluation team, chiefs of staff, and the IM. This position worked closely with the Deployment Risk Mitigation Unit Team (DRMU) to create two deployer health and safety surveys. The first survey created went out to deployed staff in the field and asked questions about their general health, safety and welfare while deployed. The second survey was sent to deployers after they returned from their tour and asked questions about the overall deployment process.

"The coolest thing about working on the team was seeing how invested leadership was in ensuring deployers had everything they needed while in the field. Data collected from the surveys was used to make permanent positive changes in the deployment process." -Jannae Parrott

Associate Assigned: Allison Gollon, Marissa Thomas, Rachel Tenerelli, Jackson Ward


Role: The Task Force Pacific Island Desk Officer served as a liaison between the Pacific Islands and the State Coordination Task Force. He/she ensured that all communications (update calls, emails, etc.) and requests with the Pacific Islands were filtered up the chain of command and to the respective task forces. He/she collected pertinent information from each territory reports the information to the Regional Operations Manager. Key functions of the officer were: training new Pacific Desk Officers; monitoring and triaging communications from the Pacific Islands; and communicating requests and pertinent details about the Pacific Islands to the Regional Operations Manager via documentation, emails, and verbal communication.

Marissa Thomas receiving the State Coordination Task Force- Chief of Staff "Cowboy Up" Award for her work on the Pacific Island Task Force.
"Being deployed for the Zika Response was a great opportunity showcasing the strengths of public health. During my time in Atlanta, I learned a wealth of information, improved upon my own skills, and interacted with great colleagues in the State Coordination Task Force." -Marissa Thomas
Left to right: Jennifer Johnson, Erin Laird, Sophia Grimm, and Allison Gollon

Associate Assigned: Jennifer Johnson

POSITION: Caribbean Islands Regional Desk Officer

Role: The Caribbean Islands Regional Desk Officer served as the point of contact between incident management staff in Puerto Rico and U.S. Virgin Islands and the State Coordination Task Force. He/she ensured that all communications (update calls, emails, etc.) and emergency logistical requests from the Caribbean Islands were efficiently triaged and processed. He/she collected information from jurisdiction staff and reported updates to the Regional Operations Manager and regional project officers, escalating issues as needed. Other job functions included: facilitating regular teleconferences between the State Coordination Task Force, CDC deployed staff, and local jurisdiction staff; preparing slides for the daily situation briefs; monitoring and triaging communications from the Caribbean Islands; and updating the Zika regional dashboard with case counts, Zika Prevention Kit distribution, vector control activities and other information specific to Puerto Rico and the U.S. Virgin Islands.

Associate Assigned: Michael Metcalf, Hope Tranberg, and Milan Vu


Epi Team is the Dream Team. Front: Hope Tranberg (PHAP, Desk Officer), Middle: Sean Hu (Pathology Liaison), Reynaldo Grant (Staffing Coordinator) Aja Griffin (ASPH, Island and Territories Liaison), Back: Jonas Hines (EIS, Pathology Liaison).

Role: The Epidemiology and Surveillance (Epi/Surv) Desk Officer was a key member of the Epi/Surv Task Force. The individual in this role maintained a functional presence in room 3004 or on “the floor” of the EOC and served as a liaison to other functional “desks.” The Desk Officer was responsible for: (1) Triaging requests submitted to the Epidemiology and Surveillance general mailbox; (2) Maintaining a listserv of all Epi/Surv team members and updating it to add and delete members who rotate on and off the team; (3) Updating calendar and meeting requests; (3) Enter Zika receipts and final reports into Zika tracker spreadsheet; (4) Sitting on Clinical Inquires calls with CDC representatives and nationwide healthcare professionals who ensure proper guidance on Zika testing for treating/caring for pregnant/parenting mothers.The Epidemiology and Surveillance (Epi/Surv) Desk Officer was a key member of the Epi/Surv Task Force. The individual in this role maintained a functional presence in room 3004 or on “the floor” of the EOC and served as a liaison to other functional “desks.” The Desk Officer was responsible for: (1) Triaging requests submitted to the Epidemiology and Surveillance general mailbox; (2) Maintaining a listserv of all Epi/Surv team members and updating it to add and delete members who rotate on and off the team; (3) Updating calendar and meeting requests; (3) Enter Zika receipts and final reports into Zika tracker spreadsheet; (4) Sitting on Clinical Inquires calls with CDC representatives and nationwide healthcare professionals who ensure proper guidance on Zika testing for treating/caring for pregnant/parenting mothers.

"Working with CDC Epi Team in Atlanta was a great and rewarding experience. It was a privilege to serve in any way necessary, and to meet many incredible individuals passionate about making this world a safer and healthier place to live in." -Hope Tranberg

Associates Assigned: Guadalupe 'Pita' Gomez


CDC Research Team with Community Partners in Bainbridge, GA Left to right: Outreach Coordinator; Pita Gomez, BA (Note taker/Project Manager); Capt. Holly Ann Williams, PhD (Co-PI), Outreach Worker, Eva De Vallescar, MA (FGD and KII Moderator), Kendra Hatfield-Timajchy, PhD (Co-PI)

Role: Pita helped with the Rapid Qualitative Assessment of Migrant Farmworkers in August 2016. The team conducted key informant interviews (KIIs) and focus group discussions (FGDs) in three states (California, Georgia, and Texas) to better describe migrant farm workers’ understanding of the Zika virus and Zika communication messages and their access and willingness to use public health interventions (such as insect repellents and condoms) to prevent the spread of Zika. As the bilingual note taker, Pita worked with the moderator to conduct all FGDs and KIIS in Georgia and Texas, while another moderator and note taker worked in California. Upon returning from their field research, Pita was designated as the project manager. She was responsible for typing and translating all field notes, communicating with the California research team to ensure timeliness of the FGDs and KIIs conducted, coordinating onboarding efforts for five bilingual Spanish/English speakers from CDC and Emory University, distributing field notes and digital recordings to these individuals to check for accuracy and augment the content of transcribed field notes, and consistently updating the task force and research team with their progress. Once Pita received all field notes from the bilingual speakers, she worked with the principal investigators on data analysis and preparing a preliminary report for the task force. Even after her designated deployment, Pita worked with the research team to finalize the report and ensure completion of all clearance levels for the PI to present the research at the “Society for Applied Anthropology” Conference in April 2017. Because Pita majored in Anthropology and her grandmother was a migrant farmworker, this research project hit very close to home and she is very grateful to have had the opportunity to work in this capacity for the Zika response.

Field Deployments

Associates in the field played an integral, grassroots role in the success of the Zika response in the U.S. and its territories. By reaching out to their respective target communities and engaging people in the fight against the Zika virus epidemic, associates led efforts to better understand the outcomes of Zika infection and to control and prevent further transmission.

Stories from Associates Deployed to the Field

Associate Assigned: Charles Futoran and Katherine Chu


Role: Field Data Entry Associates performed data entry at the Arboviral Diseases Branch Lab in Fort Collins, CO. Responsibilities included: entering Zika virus sample submission form information into the Arboviral Database (approx. 10,000 samples!); communicating with state epidemiologists concerning test results, missing patient information, and other questions they may have had; filing paper submission forms with test results after results were reported; and assisting the lab as necessary.

"I was really lucky to be a part of the Zika Response in the Fort Collins CDC Lab. I spent three months there and from the day I arrived to the day I left, I was inundated with data entry, reports, and emails with state epidemiologists. It was a great experience to learn about the processes behind a response and also getting to know the microbiologists and epis." -Katherine Chu
Charles Futoran and Katherine Chu at the lab in Fort Collins.

Associates Assigned: Brittney Odom and Henry Olano-Soler

POSITION: Global Migration Task Force

Henry providing community outreach in Vieques Island, PR

Role: Associates were deployed to the Miami and San Juan Quarantine Stations to respond to the emerging Zika epidemic and protect the health of travelers. They were responsible for providing support and leadership in port of entry communications, health education, community outreach and epidemiological projects. Associates collaborated with local, state, territorial and federal partners to protect US borders and control and prevent the spread of Zika.

Henry's Experience: Henry was stationed at the San Juan Quarantine Station (SJQS). The team’s focus was traveler’s health and its objectives involved community outreach, port-of-entry communications and epidemiological understanding of travelers to Puerto Rico. Henry quickly became immersed in each of these objectives as the traveler’s health team liaison to the Emergency Operations Center (EOC). There he collaborated with all the partners in the Zika response working on community outreach and communications in an effort to streamline the services provided to the traveler community. Additionally, he represented the SJQS at weekly Zika-related Global Migration Task Force (GMTF) communications meetings, where all traveler’s health communications efforts in the United States were discussed. Finally, he was involved in the draft and proposal of a traveler’s health epidemiological study in coordination with multiple states and territories.

Henry and Jeffery at the PR EOC with Incident Manager, Dr. Brenda Rivera, DVM
"This was a rewarding professional and personal experience where I was able to meet and learn from public health professionals at the local, territorial and national level, and to collaborate in engaging the communities of Puerto Rico in the fight against this complex emerging epidemic." -Henry Olano-Soler
Brittney Odom

Brittney's Experience: While on the Florida Zika Response, Brittney’s main role was that of Zika Coordinator for all Zika 101 basic trainings. Her responsibilities included scheduling, coordinating, and administering vital Zika 101 trainings to cruise line medical staff and other cruise line employees, Miami-Dade/Fort Lauderdale International Airport Aviation staff, High Risk Airline managers and staff across the state of Florida, Airport and Seaport first responders such as Fire and Rescue and Emergency Medical Services (EMS), TSA, Customs Border and Protection (CBP) in Miami’s jurisdiction; which includes: Florida, Alabama, Mississippi, Bahamas, and Aruba. This audience was vital because they have the most frequent and direct interaction with travelers, and the ability to disseminate the information quickly.

"During my deployment, and with the assistance of the Miami Quarantine Station I was able to schedule over 150 trainings that reached over 2000 people including 90 percent of South Florida's Carnival Cruise Line medical staff, and over 200 Royal Caribbean global medical staff" -Brittney Odom

Associates Assigned: Marrielle Mayshack and Chelsea Major


Role: The Puerto Rico Guillain-Barré syndrome (GBS) team was formed in February 2016 as part of the Zika Virus Response headed by Puerto Rico Department of Health (PRDH). After local transmission of Zika virus was identified on the Island in late 2015, PRDH collaborated with the CDC to prepare for a possible increase in the incidence of GBS, as had been reported by several other countries with ZIKV outbreaks. The team started with three primary objectives: (1) establish a GBS surveillance system to identify incident cases and provide Zika virus testing, (2) characterize historic occurrence of GBS, and (3) conduct a case-control investigation to identify risk factors for GBS in Puerto Rico. Over the course of 2016, all three objectives were met, and the team has been able to contribute substantially to evidence supporting an association between Zika virus infection and the development of GBS. Currently, the team is conducting an evaluation to assess the sensitivity of the GBS surveillance system during 2016 and following up with GBS cases to assess long-term disability.

"I had the opportunity to work with such talented and passionate people who wanted to positively impact our community. There were numerous challenges that we endured establishing the surveillance system. We faced the barriers as a unit and always remembered our public health mission. As the response continues, I am no longer physically apart of the GBS team or in Puerto Rico. However, my heart is still there passionately fighting Zika virus alongside my teammates." -Marrielle Mayshack
Left: Marrielle (left) and Chelsea (right) in Humacao at Hospital Oriente during their first solo trip of chart abstraction! | Right: GBS team celebrates Marrielle's last day in PHAP with a re-creation of her favorite food truck.
"My primary role is data manager, but I have been able to do a little of everything due to the evolving activities of our team...Whether we are going door-to-door to recruit study participants, picking up patient specimens in a hospital, or analyzing data, they are always using the opportunity to promote Zika virus awareness and prevention and to help improve the care and well-being of GBS patients." -Chelsea Major
Left: The first GBS case-control outing in April 2016. | Right: The last GBS case-control investigation adventure in January 2017!
(Left to right) Jacqueline Crain (2014 PHAP), Nina Johnson, and Carolyn Brent (2015 PHAP) assisting with the community serosurvey

Public Health Associates Carolyn Brent and Jacqueline Crain worked on Zika at their respective host sites, the Salt Lake County Health Department and the Utah Department of Health. Among other duties, Carolyn worked to educate the public and providers, coordinate testing and follow up for Zika virus cases, and report lab results from travel-acquired cases that occurred within the county. After returning from a Zika deployment to Puerto Rico, Jacqueline began helping the state update their Zika virus disease plan and testing algorithm, as well as liaising with providers and county health departments about the virus. Neither of them expected that Utah would soon be drawing national media attention for one of the most unusual Zika cases in the country.

In July, Carolyn was handed a death certificate for a patient whose cause of death was listed as dengue fever but who had no laboratory evidence of an acute dengue infection. To her surprise, the patient tested positive for Zika virus with a viral load 100,000 times higher than that of the average Zika-positive patient. When she called the provider to report the results, Carolyn learned that the patient had passed away after experiencing very severe symptoms of Zika virus, which the patient contracted abroad. This was the first Zika-related death in the continental United States.

As part of the contact investigation, the patient’s wife and a handful of other family contacts came in to meet with Carolyn and county staff the next day. During the meeting, staff noticed that one of the family members had obvious conjunctivitis, although he had not traveled to an area with known Zika virus transmission. Nonetheless, the hospital decided to test him. He tested positive.

CDC deployed a support team of specialists in vector borne diseases, hospital acquired infections, and media relations to find out how the family contact (Patient A) contracted the virus and to test if anyone else may have been infected. After interviewing Patient A, the team determined that he had none of the known risk factors for Zika virus, including travel or sexual contact, although he did have close contact with the patient that passed away (index patient). They investigated three possible modes of transmission:

Possibility 1: The virus can be passed through body fluids

Carolyn and others on the investigation team identified and interviewed 19 family contacts in English and Spanish, asking about their types of exposures to the index patient, symptoms, and mosquito exposures. They tested them all for Zika virus, but only Patient A tested positive. They also sent out a questionnaire to healthcare workers who had cared for the index patient before he passed away asking about their care activities, personal protective equipment, and symptoms. All 86 healthcare workers tested negative for Zika virus.

Possibility 2: Utah has Aedes aegypti or Aedes albopictus

Although Utah was not thought to have the mosquito vector for Zika, to cover all bases, local mosquito abatement districts partnered with CDC to trap mosquitos around the two residences where the index patient resided. No invasive Aedes species (Aedes aegypti or Aedes albopictus) were found, and all captured mosquitoes tested negative for Zika virus.

Possibility 3: Local species of mosquitos could transmit the virus

The investigation team designed a community serosurvey to detect whether residents in the neighborhoods where the index patient resided could have contracted Zika virus from the local mosquito species, which are not typically vectors for Zika. On a hot weekend Carolyn, Jacqueline, and the rest of the team spent hours knocking on doors in these neighborhoods and asking residents to fill out questionnaires (in English and Spanish) on mosquito exposure and symptoms. Phlebotomists drew blood samples from 132 willing participants. All specimens provided were negative for Zika virus.

Since there were no other positive Zika virus cases detected, the mode of transmission from the index patient to Patient A remains a mystery. Despite not reaching a satisfying conclusion, Carolyn and Jacqueline were grateful for the opportunity to help with the exciting investigation. The close relationship and pre-established trust of the two PHAP associates proved especially useful for avoiding any negative power dynamics between the county, state, and federal levels. Likewise, the flexibility of PHAP allowed them to jump right in and serve as essential resources during a tumultuous time for Utah. More information on this investigation, the index patient, and patient A can be found in the publications listed below.

Background Information and Associate Publication

Swaminathan S, Schlaberg R, Lewis J, Hanson KE, Couturier MR. Fatal Zika virus infection with secondary nonsexual transmission. New Engl J Med. 2016 Oct;375(19):1907–9.

Brent C, Dunn A, Savage H, Faraji A, Rubin M, Risk I, et al. Preliminary findings from an investigation of Zika virus infection in a patient with no known risk factors — Utah, 2016. Morb Mortal Wkly Rep. 2016;65(36):981–2.

The mission of the Public Health Associate Program is to train and provide experiential learning to early career professionals who contribute to the public health workforce.

Public Health Associate Program Liaison Committee (PHAP LC) PHAP Liaison Committee: The collective voice of the associates.

Centers for Disease Control and Prevention (CDC) Office of State Local and Territorial Support (OSTLTS) Atlanta, GA 30329


Created with images by NIAID - "MERS-CoV"

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