Tom Frieden et. al

CDC South Florida Travel Advisory Statement and Briefing on the Zika Virus

delivered 1 August 2016

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Operator: Welcome and thank you for standing by.  At this time, all participants are in "listen only" mode for the question and answer session of the call.  If you'd like to ask a question during that time, please press star [*] followed by number one [1].  Todayís conference is being recorded.  Any objections, you may disconnect at this time.  Now Iíd like to turn over the meeting to Tom Skinner, Senior Public Affairs Officer, CDC. 

Tom Skinner: Thank you, Angela.  And thank you all for joining us today for this Zika update regarding South Florida.  Weíre joined today by the Director of The Centers for Disease Control and Prevention, Dr. Tom Frieden, who will provide some opening remarks, and then we'll get to your questions.  Heíll be joined today in the question and answer session by: Dr. Lyle Petersen, whoís the Incident Manager for CDC Zika Virus Response; Dr. Denise Jamieson, Co-Lead Of The Pregnancy And Birth Defects Team on the CDC Zika Virus Response Team; and Dr. Marc Fischer, a Medical Officer from CDC's Arboviral Diseases Branch, who is in Florida. So with -- without further ado, Iíll turn the call over to Dr. Frieden. 

Tom Frieden: Good afternoon, everyone, and thank you for joining us.  This past Friday, we indicated that an area north of downtown Miami had active transmission of the Zika virus.  And we said then that we would monitor that situation every single day. New assessments of mosquito populations and new test results from this past weekend by Florida public health officials have found persistent mosquito populations and additional Zika infections in the same area.  This suggests that there's a risk of continued active transmission of Zika in that area.

As a result, CDC and Florida are issuing travel and testing recommendations for people who traveled to or live in the Florida designated areas on or after June 15th, 2016.  That date is the earliest known date that one of the individuals who became infected with Zika could have become infected, as far as the information we have as of today.

At the request of Governor Scott of Florida, we're sending a CDC Emergency Response Team (or CERT team) to Florida.  We already have two staff on the ground in Florida, three more en route today, and two more will be arriving in Florida -- no, three more, I should say, will be arriving in Florida tomorrow. These experts include individuals with extensive experience in Zika, in addressing pregnancy and birth defects, in mosquito control, laboratory science, and community engagement.

The bottom line of this announcement is that we advise pregnant women to avoid travel to this area and pregnant women who live or work in this area and their partners to make every effort to avoid mosquito bites and to prevent sexual transmission of ZikaThis advice applies to anyone who lives in or has traveled to this area any time after June 15th -- again, the earliest known date that one of the cases could have been infected with Zika.

Iíd like to step back for a moment and talk about Zika more generally. As we've said since the beginning of this unprecedented outbreak, we are learning something new about Zika every day.  We make decisions to update our recommendations and guidance on a day-by-day basis.  What we know about Zika is scary.  Zika can cause microcephaly, and this is the first time we've seen a devastating birth defect result from a mosquito bite; and it causes microcephaly even among women who don't appear to have had any symptoms of Zika infection.

But in some ways what we don't know about Zika is even more unsettling.  We don't know the long-term impact Zika may have on children born to infected mothers who don't have obvious signs of microcephaly, and these effects may only become apparent months or years in the future.  We also don't yet have ideal ways to control the particular mosquitoes that spread Zika, and we need better methods and tools for mosquito control. 

In Miami, aggressive mosquito control measures don't seem to be working as well as we would have liked.  This may happen for at least one of three reasons.

First, it's possible that the mosquitoes there are resistant to the insecticides that have been used.

Second, it's possible that there are what we call cryptic breeding places or small amounts of standing water where mosquitoes continue to hatch.

And third, it's possible simply that this is a very difficult mosquito to control, particularly in a complex urban environment like the one North of downtown Miami.

In any case, the vector control expert CDC sent will work with Florida authorities to begin resistance testing so we can determine whether mosquitoes in this area are susceptible to the insecticides being used.  That testing, however, is complex and takes at least a week and sometimes three weeks or more.

So the mosquito control experts in Florida, who have extensive experience with mosquito control, as well as our own mosquito control experts, are meeting intensively to outline additional measures that may be taken to reduce mosquito populations.

At CDC, more than 1,600 of our experts have been working since January to learn more about Zika and protect the health of pregnant women and others.  Based on what we know now about the situation in the community North of downtown Miami, in Florida, we recommend the following:

- First, that pregnant women not travel to the identified area.

- Second, that pregnant women and their partners who live in this area make every effort to prevent mosquito bites and prevent sexual transmission of Zika.  This includes applying insect repellent containing DEET to uncovered skin, wearing long-sleeved shirts and long pants, using and repairing screens on windows and doors, and using air conditioning when available, and removing standing water where mosquitoes lay eggs;

- that pregnant women who traveled to this area on or after June 15th talk with their health care provider to be tested for Zika;

- that pregnant women without symptoms of Zika who live in or frequently travel to this area be tested for Zika in the first and second trimesters of pregnancy;

- that male and female sexual partners of pregnant women who live in or have traveled to this area consistently and correctly use condoms or other barriers against infection during sex --  for the duration of pregnancy;

- that all pregnant women throughout the U.S. be assessed for possible Zika virus exposure during each prenatal care visit and tested according to our guidance;

- that women and men who traveled to this area and have left the area wait at least eight weeks before trying for a pregnancy;

- men with symptoms of Zika should wait at least six months before trying for a pregnancy; 

- and that anyone with possible exposure to Zika and symptoms of Zika be tested for the infection. 

We do expect that additional individual infections will be reported.  There are undoubtedly more infections because most people infected with Zika don't have symptoms.  People infected a week or two ago may also have their infections diagnosed.

Nothing that we have seen indicates widespread transmission but it's certainly possible there could be sustained transmission in small areas.  This is particularly a risk for people who don't have screens or air conditioning and who live in crowded spaces.

Weíll continue to update you with what we know when we know it.  We understand that people want more information and are understandably concerned about Zika here and elsewhere.  We wish we had all of the answers, but the fact is this is a new phenomenon.  Zika was not known to cause microcephaly even a year ago, and we continue to learn more each day about Zika.

Weíre doing all that the science can allow to get answers and working around the clock to prevent infections.  Florida is working hard to reduce the risk of Zika infection and to protect pregnant women.

The bottom line here is that because mosquito-control efforts in the specific community, one-mile radius north of downtown Miami, don't appear to be working as well as we would have hoped, and because we've seen more Zika cases over a longer time frame, we advise pregnant women to avoid travel to this area and pregnant women who live or work in this area to make every effort to avoid mosquito bites.

Thank you. 

Tom Skinner: Angela, I think we're ready for questions, please.  Weíll allow reporters to ask a question and a follow-up and then move to the next question. 

Operator: Thank you.  We will now begin the question and answer session.  If you'd like to ask a question, please press star [*] followed by number 1 [1].  Our next -- Our first question comes from Richard Besser with ABC news. 

Richard Besser: Thanks very much.  Can you hear me? 

Tom Skinner: Yes.  Go ahead, Rich. 

Richard Besser:  Thanks...a lot, Dr. Frieden.  I...have a question about limiting the -- the travel advisory to such a small area. Has there been additional testing to show that you've been able to, or Florida has been able to limit the mosquito in the other parts of Miami?  And have they done urine testing beyond this...affected neighborhood? 

Tom Frieden: The Miami and Florida officials are doing additional urine testing.  Our understanding is there have been several investigations over the past weeks; and in other investigations no additional cases have been identified -- or infections have been identified, I should say.

In this particular neighborhood, in the 150-meter area around the two workplaces where two initial cases were found, multiple additional infected individuals were identified. Those individuals were all identified within that 150-meter area. Florida is following the recommendation of going to about five times that distance to have a buffer zone in a one-mile radius around the very specific area where the virus has been spreading.

We know that Aedes aegypti mosquitoes are present widely, not just throughout Miami but throughout 30 states in the U.S. -- and anywhere these Aedes aegypti mosquitoes are present, women should take steps to protect themselves, pregnant women in particular, to protect themselves against mosquito bites.

Richard Besser:  ...thanks very much.  And just in follow-up, you know England and Ireland have...put out a recommendation to the entire state of...Florida.  Do -- Do you think that's overkill?

Tom Frieden:  The information I saw from Public Health England referred to the several- block area in the north of downtown Miami.  So I'm -- I'm not sure if the travel recommendation is broader than that.  But we recommend specific to this neighborhood.  We will reassess that on a daily basis.

But it's very important to be clear that the way Zika spreads is different from the way other mosquito-borne viruses spread.  Zika is spread by the Aedes aegypti mosquito.  There isn't a --an animal reservoir, so unlike West Nile, which persists in the bird population and can affect an entire state, with Zika it is quite focal and generally requires that mosquitoes get re-infected or infected by people [who are] infected.  So [it] persists where there is a crowded population without access to air conditioning or screens and the presence of large numbers of mosquitoes.

So we'll be looking very carefully a[t] Florida, around this area, to see if there are other people who have been infected, but in the other investigations that they have done, they have not found other infected people.  In this particular investigation, they did find additional individuals both at the workplace, where one of the initial workers was -- was diagnosed, was from, and in the community within this 150-meter area.  Thank you. 

Richard Besser:  Thanks very much. 

Tom Skinner:  Next question. 

Tom Frieden:  Angela, we can take the next question. 

Operator: One moment please for the next question...Next question comes from Betsy McKay with "Wall Street Journal." 

Betsy McKay: Hi.  Thanks very much.  I wanted to follow up on that last comment, Dr. Frieden.  You said they found -- was this everyone?  Were all 14 people found within this 150-meter area around the workplace, either at the workplace or in the community?  Was that everybody, or are there, you know, some people who may have been infected, you know, in that neighborhood but outside that 150-meter area?  And then my second question was, you mentioned that the, you know, mosquito populations aren't coming down because of possible resistance.  Do you know what insecticide or insecticides are being used?

Tom Frieden: Thank you, and Iíll refer you to Florida for the details of those questions, but my understanding, which should be confirmed with Florida is that 12 of the 14 infections so far diagnosed, that are referred to in Governor Scottís press release today, occurred in this 150-meter area.  Thatís a large number, but not a surprising number.  We had two symptomatic infections or three symptomatic infections and we do expect at least four asymptomatic infections for each symptomatic infection. In addition, as I mentioned in my opening remarks, we may well see other infections in that area because of how efficient a vector this particular mosquito is.  And in terms of insecticides, our understanding is they've used at least two different products from the pyrethroid class.  Next question, please. 

Operator: Next question comes from Nick Valencia with CNN.

Nick Valencia: Hello, Dr. Frieden.  Thanks for taking the question.  Iím here in Wynnwood [Florida] and I have been for the last three days.  And about ten minutes ago, I saw a pregnant woman walking through this neighborhood who told me that she plans on ignoring the CDC advisory and, unfortunately, those that Iíve spoken to here echo the same sentiment.  Is there anything more that can be done?  Are you considering more aggressive steps, or considering other action, in light of this information?  Because people just don't seem to be paying attention and are blaming us for perhaps even causing fear among the locals.

Tom Frieden: I think what you are experiencing there is something that we have seen surprisingly often in the Zika response.  Iím sorry that people feel that way, but it -- it is a problem.  But generally, we take most seriously those threats that are about to happen.  And one of the challenges with Zika is, first, people don't get sick, because four out of five have no symptoms at all and the last has relatively mild symptoms usually; and second, the problem is six, seven, eight months away when a -- a baby with microcephaly is delivered.

But [the] tragedy of a preventable case of a severe birth defect is something that I think we have to make very clear to people. If you see the pictures and the stories from Brazil, from Colombia, from elsewhere, where women are delivering children with microcephaly -- and if you think about the uncertainty we have that many, many more babies are born to women who were infected with Zika than there are babies born with microcephaly and we don't know if those babies will have neurological problems later in life. It is truly a scary situation, but it's not immediately apparent to people that it is this kind of a significant risk.

So we appreciate your work at making clear what this means for individuals. I think any parent wants the best for their child, and being able to do whatever we can so that we're providing information to the public and, in particular, to pregnant women and their providers so that they can take steps to protect themselves and their pregnancy is really our responsibility and our commitment.  Do you have a follow-up question? 

Nick Valencia:  Well, I'm...I have a follow-up question about the vector control team, the numbers.  Is it eight total from the CDC? 

Tom Frieden: So the -- it's called a CERT team. It includes vector control as well as a variety of other expertise, including birth defects, laboratory science, communications, and the... Zika virus itself, and pregnancy and birth defects.  And eight is the correct number -- at this time.  Weíll have more, if needed.  We already, as I mentioned, have two staff on the ground, three en route, and three more coming tomorrow.  Itís called a CERT team, C-E-R-Team -- C-E-R-T -- CDC Emergency Response Team.  Next question, please. 

Nick Valencia: Thank you. 

Operator: Next question comes from Mike Stobbe with The Associated Press.

Tom Skinner: Mike, do you want to go ahead?

Mike Stobbe: Yeah, can you hear me?

Tom Skinner: Yes. Go ahead.

Mike Stobbe: Thanks. First question: Could you say a little bit more about, again, on the theme of the -- the aggressive mosquito measures, the control measures [that] don't seem to be working?  Can you tell us how that -- that's been measured and -- and what the numbers are that show that it hasn't been working?  And my second question was: Could you say, just for historical context, when is the last time the CDC or any federal public health agency has advised any members of the public not to travel to some area in the continental United States?

Tom Frieden: So in answer to your first question, we would refer you to Florida.  Our vector control expert is arriving today.  But from the information that we have heard, despite the daily use of spraying, the vector control experts there were still seeing new larval mosquitoes and moderately high Aedes aegypti counts -- which is not something that we hoped to see. And as I mentioned, this could be because of insecticide resistance. It could also be because of cryptic breeding sites or simply that this is a very difficult mosquito to control.  And in -- with regard to your second question, as far as we know, we can find no similar recommendation in recent years.  Of course, Puerto Rico is part of the U.S. and January 15th of this year, we issued recommendations relating to Puerto Rico.  Next question, please. 

Operator: Okay.  [The next question comes] from Liz Szabo with "USA Today." 

Liz Szabo: Thanks.  He just answered my question. 

Tom Frieden:  Okay, next question. 

Operator: Next question comes from Daniel Chang with the "Miami Herald." 

Daniel Chang: Hi, Dr. Frieden.  Thank you for taking my call.  I was hoping that you might be able to better identify this 150-meter area that you referred to in your opening comments.  The...Florida Department of Health is still giving us the one square mile area -- and that was my first question.  My -- My follow-up question was related to the CERT team and at which point they would be dispatched.  I know that it requires a state's request, but as I saw in the plan that the CDC released earlier, there are different stages at which they could request a CERT team.  So I was curious, when was the earliest that Florida could have asked for that -- that assistance?  Thank you.

Tom Frieden:  So, thank you.  First, in terms of the 150-meter area, I would refer you to the Florida health department.  I will say it's generally in the center of that one-mile block so that it's kind of -- there's a buffer zone all around it with natural boundaries.

In terms of the CERT team, the CERT team -- actually members of it are -- are already there and have been there since last week -- and as I mentioned, will be there today and tomorrow, the full CERT team will -- will have arrived.  And we've had very close coordination, collaboration with Florida from the beginning of this.  Iíve been in essentially daily conversations with the surgeon general of Florida, Dr. Celeste Philip.

We've also been in regular coordination between our experts and theirs.  The Florida laboratories have been really at the forefront of some of the innovations and laboratory testing for Zika.  So there's a close collaboration here, and this just steps it up to the next level. 

Daniel Chang: Thank you. 

Tom Frieden: Next question, please. 

Operator:  Next question comes from Jonathan Serrie with Fox News. 

Jonathan Serrie: Hi, Dr. Frieden.  You had mentioned that there's no animal reservoir for this particular virus with the -- the way the mosquito's transferring it. So, I'm assuming this is a case where an infected traveler returns from a country or territory with active Zika transmission, gets bitten by local mosquitoes which in turn passes on to others.  What can you tell us about patient zero or how this virus moved into south Florida? 

Tom Frieden: Well, because four out of five infections are without symptoms, it's unlikely that we'll ever know exactly who brought it in, where they brought it in from.  Thatís why it's so important that anywhere in the U.S. there are Aedes aegypti mosquitoes, pregnant women take steps to protect themselves, because itís possible there are, well, occasional transmissions in local areas that may be inapparent because, again, four out of five infections are asymptomatic.  I know thatís unsettling and in some ways unsatisfying, but that's the way the world works.

And what we do is take that and then say, "What can we do to be maximally protective?" We know, with 1600-plus infections documented in the U.S., there are many times that -- that number of people who've actually had the disease in the U.S. because most asymptomatic people aren't tested -- they'd really be the few asymptomatic diagnoses we have are of pregnant women in this country.

So with 40 million-plus travelers to and from affected areas, and intense transmission in Puerto Rico and elsewhere in the Caribbean and in the hemisphere, we know there will be a continuing stream of people coming back from business trips, from travel to visit relatives, from vacations, who may feel perfectly fine but don't have any symptoms.  Everyone coming back from somewhere where Zika is spreading should use mosquito repellent for three weeks to protect their family in case a mosquito bites them and then gets infected.

And what you say is exactly correct.  The way this is generally spread is that the mosquito hitchhikes in the blood of a traveler and then is bitten by -- when that traveler is bitten by another mosquito, that mosquito then develops the infection and then can bite others.  So this is why it's so important that, first off, all pregnant women in areas where Aedes aegypti is spreading protect themselves from mosquito bites; and all travelers returning from infected areas use mosquito repellent for three weeks to protect their family and their community.  Do you have a follow-up question? 

Jonathan Serrie: No, I don't.  That answers it.  Thank you. 

Tom Frieden: Thank you.  Next question. 

Operator: Next question comes from Lena Sun with "The Washington Post." 

Lena Sun: Hi, Dr. Frieden.  Can you say anything about whether there is anything unusual that the mosquito folks are -- are seeing about Aedes aegypti in this particular area? You mentioned, you know, they may be hiding out in these cryptic areas.  I was wondering if there's anything that's come up about the way this mosquito is behaving?  Thatís one.  And the second -- my follow-up question has to do with the workplace, the workplace where a lot of this has been occurring. Have those workplaces taken extra precautions to warn their workers to get tested or spray or do additional -- take additional measures? 

Tom Frieden:  Thank you.  Whatís, I think, challenging about this area is that it's a mixed- use area, and has many different types of buildings and locations present -- from industrial to residential; from high end to -- to more economically stressed; from areas that we've seen on the news where there's a lot of nightlife; to areas that are more isolated.  So it's an unusual area in that regard or -- not unusual but an area that's not a wall of one type or another type. And that does make mosquito control more difficult because you need to tailor the mosquito-control activities to the specifics of the area to get rid of breeding sites as well as apply larvacide and -- and insecticide effectively.

In terms of the workplace Iíd have to refer you to Florida. I know theyíve been quite cooperative and extensive sampling was done at the workplace as well. 

Lena Sun: Thank you. 

Tom Frieden:  Next question. 

Operator: Next question comes from Pam Belluck with "[The] New York Times." 

Pam Belluck: In -- In Governor Scottís press release, he said that CDC was advising not only pregnant women but women considering becoming pregnant or thinking about becoming pregnant.  Are you extending it to that population as well?  And as a follow-up, I -- he had said that six of the ten new cases were -- were not symptomatic.  I assume that four then were?  And were they all identified by, you know, kind of urine testing of people in the area, or were any of them identified because they showed up with symptoms elsewhere? 

Tom Frieden: Okay, Iíll answer the second of those questions and then ask Dr. Denise Jamieson to [answer] the first of them.  The details of the investigation again Iíll refer you to Florida.  Our understanding is that they did surveys both at the workplace, as well as in the community.  And for the -- for the community survey, they identified six asymptomatic people with positive urine PCR, implying infection within the past two weeks.  For the workplace, they identified individuals with both positive PCR and positive IGM.  Some had symptoms and some did not. And so Iíll refer you to the state for those details.  Dr. Jamieson?

Denise Jamieson: So we are advising that pregnant women not travel to this area that the Florida Department of Health has identified.  In addition, we're recommending that women who are considering pregnancy not get pregnant for up to eight weeks after returning from that area. 

Pam Belluck: Okay.  If you're considering pregnancy, then you can travel there, just don't get pregnant for eight weeks. 

Denise Jamieson: Correct. 

Pam Belluck: Okay. 

Tom Frieden: Next question, please. 

Operator: The next question comes from Robert Lowes of MedScape Medical News

Robert Lowes: Yes, Dr. Frieden, thanks for taking all our calls.  In the press release from Governor Scott, he said that Florida remains safe and open for business.  He said, you know...we already welcomed 30 million tourists.  We look forward to welcoming more visitors to Florida -- Florida this summer.  Did Florida ask the CDC to limit the size of this travel advisory area -- the known transmission area to that particular dimension to basically protect the tourist -- tourism industry in Miami?

Tom Frieden: No.  In fact, this is consistent with the CDC guidance that we had already published and have updated more recently.  The guidance basically takes into account that the Aedes aegypti mosquito doesn't travel more than 150 meters in its lifetime and that within the U.S., transmission that we've seen of dengue and Chikungunya has been very focal -- so it -- there wouldn't be a technical or scientific basis to give a broader recommendation.  We don't have evidence that thereís spread more broadly.  We do know that all throughout parts of 30 states of the U.S., we have Aedes aegypti mosquitoes.  And in all of those places, pregnant women should protect themselves against mosquito bites.

But here, the importance is to be specific so that people in that area can take steps to protect themselves and can avoid travel to that area if they're pregnant.  We will continue to look at this data every single day, including additional testing, and if that changes [in] Florida, then we will adjust the area of warning. 

Robert Lowes:  Thank you. 

Tom Frieden:  Next question. 

Operator: Next question comes from Helen Branswell with STAT.

Helen Branswell: Hi.  Thanks very much for taking my question.  Dr. Frieden, you mentioned that the -- the vector control efforts don't seem to be working as well as they ought to be.  What is showing up in their traps? Is it mostly Aedes aegypti?  Is it anything else? And I don't think there's been any positive hits yet in terms of infected mosquitoes, have there? And I have a follow-up question, if I could.

Tom Frieden: Thank you.  They're using traps that are specific for Aedes aegypti and they're catching mostly Aedes aegypti.  As far as we know they've not had any positive mosquitoes.  And we -- we don't expect that.  Itís kind of like looking for a needle in a haystack to get a positive mosquito. We generally find that for determining if there is local transmission, unfortunately, finding cases in people is much more sensitive than finding infections in mosquitoes.

Helen Branswell:  Okay. My follow-up question, I think Dr. Petersen is on the line.  I know you folks out in Fort Collins have been doing work looking at potential vectors for -- for Zika, and particularly whether some of the mosquitoes that are more prevalent in the -- the United States could be competent vectors.  Are you seeing any sign that anything else is -- is a potential problem? 

Dr. Lyle Petersen: Right. That work is ongoing.  So far to date, they've been looking at Culex mosquitoes, which are the ones that spread West Nile. And weíve found no evidence to date that the virus can be propagated in those mosquitoes.

Helen Branswell: Thank you.

Tom Frieden: Weíll take two more questions. 

Operator:  Next question comes from Nancy Cook with Politico.

Nancy Cook: Hi. Thank you so much for taking my question.  Hello? 

Tom Frieden:  Yes, go ahead. 

Nancy Cook:  Yeah.  I just was wondering, you know, on the Friday call, the CDC, you were saying that, you know, there was no need to issue any sort of travel ban.  And Iím wondering what has changed.  You know, it's just Monday, you know, it's just two days later.  What has changed over the weekend to make you guys alter that call?  Thank you. 

Tom Frieden: So as we said on Friday, we literally look at this every single day.  And we had basically three pieces of information come in over Saturday and Sunday.

The first and most concerning was that it appeared that the mosquito-control activities hadn't had the level of success that we had hoped.  So they're still seeing more Aedes aegypti mosquitoes (the mosquito that spreads this) than we had hoped.

Second, the additional testing which Florida did found additional cases.  And those cases went back to June 30th.  So there was more extensive spread in this area and more extensive mosquito populations than we had known on -- on Friday. And because of that, today we advise pregnant women not to travel to that area.  And we will continue with Florida to look at the data every single day.

I will say that Florida is releasing additional information on what -- what they are doing in terms of the investigation of this and other potentially locally transmitted cases.  This is not the first investigation they've done.  In other investigations they've evaluated and not found any local transmission.  In this case, they investigated and found further local -- I should say further local transmission.  And for that, they -- they basically have identified, as mentioned, 10 additional cases in this area, or infections, I should say, in this area, including six asymptomatic community members, as well as add to the two individuals who triggered the investigation here. So a total of 12 cases in this 150-meter radius.

They -- The state has tested more than 2,000 people statewide.  Theyíve tested more than 200 people through these different investigations of local or local -- potentially locally transmitted Zika, and they've identified the area where active transmission is occurring.

They are doing extensive outreach in that area and the CDC CERT team or the CDC Emergency Response Team is already either there or en route to work with Florida since the request of Governor Scott this morning, and -- but we've been working closely with Florida for weeks on this and other investigations.

And we recognize that it's a situation that changes rapidly, but this is what we've seen with Zika.  We literally are responding daily.  We work 24/7 to protect people.  And as soon as we get new information that affects how we would give guidance, we provide that new guidance. 

[I] think we have time for one last question. 

Operator: Our last question comes from Tom Howell with the ďWashington Times."

Tom Howell: Hi. Thanks for taking my call. You mentioned you don't expect widespread transmission but you do expect possible sustained transmission in these localized areas.  For people who, you know, hear that there won't be supposedly widespread infections, you know, swirling throughout the continental U.S. and -- and those who doubt that $1.9 billion number, can you explain why, you know, the $1.9 billion number is still the number that, you know, you feel is needed to combat this disease? 

Tom Frieden:  Well just to be clear, this is a really tough mosquito to control.  When Key West had an outbreak of dengue a few years back, despite extensive mosquito control efforts, that outbreak continued for more than a year.  And, therefore, it's really a demonstration of how intensive the efforts need to be to control this infection.

In addition, we know that a single child born with microcephaly represents a -- a terrible tragedy for that family, and also can cost 10 million dollars or more in medical and other costs over the lifetime of that child.

So preventing these tragic occurrences to the best of our ability requires a robust response. And that means investing today, not just in the vaccine, which is very important, but in better ways to kill mosquitoes, better ways to track mosquitoes, better ways to diagnose the infection, so that we can protect pregnant women more effectively.

Before closing, I just want to reiterate the bottom line, which is that: what we have learned over the past 48 hours is that mosquito control efforts don't appear to have been as effective as we had hoped, and a number of new cases of Zika have been diagnosed in that specific 150-meter area.  Therefore, CDC advises pregnant women to avoid travel to this one-mile radius area north of downtown Miami, and for pregnant women who live or work in the area to make every effort to avoid mosquito bites.  Thank you. 

Tom Skinner: Thank you all for joining us for this call today.  A transcript of this call will be posted to the CDC newsroom later this afternoon.  If you have follow-up questions or need additional information, please call the CDC press office at 404-639-3286.  Thanks you -- Thank you once again for joining us.  Weíll provide more updated information as we have it.  Thank you. 

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