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Contraceptive Use Among Nonpregnant and Postpartum Women at Risk for Unintended Pregnancy, and Female High School Students, in the Context of Zika Preparedness — United States, 2011–2013 and 2015 Early Release / August 2, 2016 / 65 http://www.cdc.gov/mmwr/volumes/65/wr/mm6530e2.htm?s_cid=mm6530e2_w

Ten more cases of local Zika reported in Florida Filed Under: Zika Stephanie Soucheray | News Reporter | CIDRAP News | Aug 01, 2016 Share Tweet LinkedIn Email Print & PDF wynwood.jpg Gadi Yosef/ Flickr cc Florida Gov. Rick Scott said there were 10 more cases of locally transmitted Zika virus infection diagnosed over the weekend, as Zika control measures seem to be faltering in Miami, according to the Centers for Disease Control and Prevention (CDC). Active transmission in Miami Officials from the Florida Department of Health (Florida Health) confirmed today that the 10 cases involved local transmissions, spread by mosquitoes in a small neighborhood north of downtown Miami, according to Scott. Six of the cases were asymptomatic and found through door-to-door surveillance conducted by Florida Health. The cases bring the total spread by local mosquitoes to 14 in Florida. "While we continue to learn more about this virus each day, we know that it is most harmful to pregnant women and their babies," Scott said in a statement. "For women who live or work in the impacted area and are either pregnant or thinking of becoming pregnant, I urge you to contact your OB/GYN for guidance and to receive a Zika prevention kit." Until last week the roughly 1,700 cases of Zika in US states were contracted outside the country or through sexual contact. On Friday, Florida Health confirmed that 4 cases of Zika in Miami were spread by local mosquitoes, and have tested more than 200 people in Wynwood, the affected neighborhood. In his statement, Scott also called on the CDC to activate a CDC emergency response team (CERT) to help with mosquito surveillance, trapping, and control efforts. Still, he emphasized that Florida was "open for business," even after Public Health England warned pregnant women this weekend to halt nonessential travel to Florida. "While I encourage all residents and visitors to continue to use precaution by draining standing water and wearing bug spray, Florida remains safe and open for business," said Scott. "This year, we have already welcomed a record 30 million tourists and we look forward to welcoming more visitors to Florida this summer." High Aedes counts despite spraying In a briefing today, CDC Director Tom Frieden, MD, MPH, said there was a CERT being deployed to Miami this afternoon, adding that the agency was issuing a travel ban for pregnant women to the 1-mile area where local transmission has been observed. This is the first time the CDC has issued a travel ban in the continental United States. "What we have learned in the past 48 hours is that mosquito control efforts haven't been effective as we hoped in Miami," said Frieden. Frieden said there were a few possible reasons mosquito control experts were still seeing moderately high numbers of Aedes despite daily spraying. First, the mosquitoes could be laying eggs in "cryptic reservoirs" that were hard to find and target (eg, bottle caps in a person's backyard). More worrisome, Frieden said there could be resistance to the insecticides used. Testing results on the effectives of individual insecticides being used in Miami won't be available for another 1 to 2 weeks, he said. Because 4 out of 5 infections with Zika are "silent" or asymptomatic, Frieden said protecting pregnant women or those who are considering pregnancy remains the main goal of the CDC's Zika policy. "Pregnant women should not travel to this area," said Frieden. "Pregnant women who live in this area need to take every step to prevent mosquito bites or sexual transmission. And pregnant women who traveled to this area on or any time after Jun 15 need to be tested for Zika." Frieden said that based on epidemiologic questioning, Jun 15 is the earliest date of possible local transmission in Miami. In addition to the travel ban, the CDC is recommending Zika testing for all pregnant women in the continental United States at prenatal visits in their first and second trimesters. Michael T. Osterholm, PhD, MPH, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, which publishes CIDRAP News, said that while he agrees with the CDC's decision to ban travel for pregnant women to a limited area, he warns overreaction could lead to unnecessary restrictions. "You shouldn't cease all travel to Florida," said Osterholm. "We wouldn't have a travel ban to Minneapolis, because 140 people contract West Nile Virus from mosquitoes each year in Minnesota, and one third of those cases are life-threatening." Osterholm said aggressive public health measures make travel to wider Florida safe. See also: Aug 1 Gov. Rick Scott's statement Aug 1 CDC press release Aug 1 CDC travel ban summary Aug 1 CDC travel advice for Wynwood http://www.cidrap.umn.edu/news-perspective/2016/08/ten-more-cases-local-zika-reported-florida

Old Table Reported Cases of Zika in New York City as of 7/22/2016 [Español (PDF)] Positive NYC Residents Case Type Number of Cases Locally acquired mosquito-borne reported† 0 Travel-associated* 376 Sexually transmitted: 4 Guillain-Barre syndrome: 3 Infants with birth defects: 1 Laboratory acquired 0 Total 376 Gender Number of Cases Female 270 Pregnant: 42 Male 106 Age Average Age (Range) 39 (1-74) Positive NYC Resident by Borough Number of Cases Bronx 149 Manhattan 82 Queens 74 Brooklyn 69 Staten Island 2 Unknown 0 Most Common Countries Visited Number of Cases Dominican Republic 223 Puerto Rico 29 Jamaica 25 Guyana 16 Colombia 9 Saint Lucia 8 †Presumed local mosquito-borne transmission*Travelers returning from affected areas, their sexual contacts, or infants infected in utero

New Table Reported Cases of Zika in New York City as of 7/22/2016 [Español (PDF)] Positive NYC Residents Case Type Number of Cases Locally acquired mosquito-borne reported† 0 Travel-associated* 356 Sexually transmitted: 4 Guillain-Barre syndrome: 3 Infants with birth defects: 1 Laboratory acquired 0 Travel History Pending Investigation 20 Total 376 Gender Number of Cases Female 270 Pregnant: 42 Male 106 Age Average Age (Range) 39 (1-74) Positive NYC Resident by Borough Number of Cases Bronx 149 Manhattan 82 Queens 74 Brooklyn 69 Staten Island 2 Unknown 0 Most Common Countries Visited Number of Cases Dominican Republic 223 Puerto Rico 29 Jamaica 25 Guyana 16 Colombia 9 Saint Lucia 8 †Presumed local mosquito-borne transmission *Travelers returning from affected areas, their sexual contacts, or infants infected in utero

New York City Zika tally page has re-classified 20 travel related cases to "travel history pendig investigation", http://www1.nyc.gov/site/doh/health/health-topics/zika-virus.page

Reported Cases of Zika in New York City as of 7/22/2016 [Español (PDF)] Positive NYC Residents Case Type Number of Cases Locally acquired mosquito-borne reported† 0 Travel-associated* 356 Sexually transmitted: 4 Guillain-Barre syndrome: 3 Infants with birth defects: 1 Laboratory acquired 0 Travel History Pending Investigation 20 Total 376 Gender Number of Cases Female 270 Pregnant: 42 Male 106 Age Average Age (Range) 39 (1-74) Positive NYC Resident by Borough Number of Cases Bronx 149 Manhattan 82 Queens 74 Brooklyn 69 Staten Island 2 Unknown 0 Most Common Countries Visited Number of Cases Dominican Republic 223 Puerto Rico 29 Jamaica 25 Guyana 16 Colombia 9 Saint Lucia 8 †Presumed local mosquito-borne transmission *Travelers returning from affected areas, their sexual contacts, or infants infected in utero

Map Update https://www.google.com/maps/d/edit?hl=en&hl=en&authuser=0&authuser=0&mid=1FlIB7hHnVgGD9TlbSx5HwAj-PEQ

Three new travel-related Zika cases have been reported in Mississippi, bringing the state's total to 14. A Harrison County resident who recently traveled to Honduras contracted one of the three new reported cases. The two other new cases are residents of Panola County who recently traveled to the Caribbean island of Grenada, according to a news release issued by the Mississippi State Department of Health, http://www.clarionledger.com/story/news/2016/08/01/three-new-zika-cases-reported-mississippi/87909206/

Map Update https://www.google.com/maps/d/edit?hl=en&hl=en&authuser=0&authuser=0&mid=1FlIB7hHnVgGD9TlbSx5HwAj-PEQ

At A Glance - Zika Virus in Arkansas (as of August 1, 2016) Travel-associated Zika virus disease cases reported: 8 Locally acquired cases reported: 0 http://www.healthy.arkansas.gov/programsServices/infectiousDisease/zoonoticDisease/zika/Pages/default.aspx

At A Glance - Zika Virus in Arkansas (as of August 1, 2016) Travel-associated Zika virus disease cases reported: 8 Locally acquired cases reported: 0

Map Update https://www.google.com/maps/d/edit?hl=en&hl=en&authuser=0&authuser=0&mid=1FlIB7hHnVgGD9TlbSx5HwAj-PEQ

Map Update https://www.google.com/maps/d/edit?hl=en&hl=en&authuser=0&authuser=0&mid=1FlIB7hHnVgGD9TlbSx5HwAj-PEQ

Allegheny County Residents Approved for Zika Testing: 141 CDC Confirmed Cases: 7 http://www.achd.net/topic-zika.html

Allegheny County Residents Approved for Zika Testing: 141 CDC Confirmed Cases: 7(as of August 1)

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Arizona's First Zika Case Recorded in Traveler, read the news release Travel-associated Zika cases confirmed in Arizona: 13 http://www.azdhs.gov/preparedness/epidemiology-disease-control/mosquito-borne/index.php#zika-home

Press Briefing Transcript Monday, August 1, 2016, at 1:00 P.M. EST Audio recording[MP3, 6.97 MB] Please Note:This transcript is not edited and may contain errors. OPERATOR: Welcome and thank you for standing by. At this time, all participants are in listen only mode for the question and answer session. If you'd like to ask a question, please press star followed by number one. Today’s conference is being recorded. Any objections, you may disconnect at this time. I’d like to turn over the meeting to Tom Skinner, Senior Public Affairs Officer, CDC. TOM SKINNER: Thank you, Angela. Thank you all for joining us for this Zika update regarding south Florida. We’re 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. He’ll be joined today in the question and answer session by Dr. Lyle Petersen, who’s 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 without further ado, I’ll turn the call over to dr. Frieden. TOM FRIEDEN: good afternoon, everyone. 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 are 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 -- 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 prevent sexual transmission of Zika. This 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. I’d like to step back for a moment and talk about Zika more generally. As we have 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 pants, using and repairing screens and 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 travelled 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. We’ll 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. We’re doing all that 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 and 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. We’ll 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. Our first question comes from Richard Besser with ABC news. RICHARD BESSER: Thanks very much. Can you hear me? TOM SKINNER: Yes. Go ahead, Richard. RICHARD BESSER: thanks a lot, Dr. Frieden. I have a question about limiting the travel advisory to such a small area. Has there been additional testing to show that you've been able to -- 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 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. Just in follow-up, England and Ireland have put out a recommendation to the entire state of Florida. 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 am 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 an animal reservoir. 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 persists where there is a crowded population without access to air conditioning or screens and the presence of large numbers of mosquitoes. So we will be looking very carefully as Florida around this area to see if there are other people who have been infected, but in the other investigations they've 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 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. OPERATOR: 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 I’ll 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 Scott’s press release today occurred in this 150-meter area. That’s a large number, but not a surprising number. We had two symptomatic infections or three symptomatic infections and we expect four asymptomatic infections for each symptomatic infection. In addition, as I made in my opening remarks, we may well see other infections in that area because of how efficient a vector this particular mosquito is. 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. I’m here in Wynnwood and have been for the last three days. About ten minutes ago, I saw a pregnant woman walking through this neighborhood who told me she plans on ignoring the CDC advisory and, unfortunately, those that I’ve spoken to here echo the same sentiment. Is there anything more that can be done? Are you considering more aggressive steps for 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. I’m sorry that people feel that way, but 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 baby with microcephaly is delivered. But the tragedy of a preventable case of a severe birth defect is something I think we have to make very clear to people. If you see the pictures and the stories from Brazil and Colombia and elsewhere where women are delivering children with Microcephaly and if you think about the uncertainty that many many more babies 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 am -- I have a follow-up question about the vector control team, the numbers. Is it eight total from the CDC? TOM FRIEDEN: It's called a CERT team and 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. We’ll have more if needed. We already, as I mentioned, have two staff on the ground. Three en route and three more coming tomorrow. It’s called a CERT 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. MIKE STOBBE: Yeah, can you hear me? MIKE STOBBE: Thanks. First question, could you say a little more about, again, on the theme of the aggressive mosquito measures that don't seem to be working. Can you tell us how that's been measured 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 that 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'd refer you to Florida. Our vector control expert is arriving today. But from the information that we 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. As I mentioned, this could be because of insecticide resistance and cryptic breeding sites or that this is a very difficult mosquito to control. And 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 refer 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 follow-up question was related to the CERT team and at which point they would be dispatched. I know it requires a state's request. As I saw in the plan that the CDC released earlier, there are different stages at which they could request a CERT team. What is the earliest that Florida could have asked for 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 already there and have been there since last week. And as I mentioned, will be there today and tomorrow, the full CERT team will have arrived. And we've had very close coordination, collaboration with Florida from the beginning of this. I’ve been in essentially daily conversations with the surgeon general of Florida, Dr. Celeste Philip. Also 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. TOM FRIEDEN: Next question comes from Jonathan Serrie with Fox News. JONATHAN SERRIE: Hi, Dr. Frieden. You mentioned there's no animal reservoir for this particular virus with the way the mosquito's transferring it. A traveler returns from a country or territory with Zika transmission, gets bitten by local mosquitoes which then pass this 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. That’s why it's so important that anywhere in the U.S. there are Aedes aegypti mosquitoes that pregnant women take steps to protect themselves. It’s possible there are occasional transmissions in local areas that may be inapparent because, again, four out of five infections are asymptomatic. I know that’s unsettling and in some ways unsatisfying, but that's the way the world works. 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 number of people who have actually had the disease in the U.S. because most asymptomatic people aren't tested. Really the few asymptomatic diagnoses we have are pregnant women in this country. Sso 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. 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 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 seeing about Aedes aegypti in this particular area? You mentioned 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? That’s one. And 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. What’s, 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 more economically stressed. From areas that we've seen on the news where there's a lot of nightlife. 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. That does makes 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 insecticide effectively. In terms of the workplace I’d have to refer you to Florida. I know they’ve 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 "New York Times." PAM BELLUCK: In Governor Scott’s 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, he had said that six of the ten new cases 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: I’ll answer the second of those questions and then ask Dr. Denise Jamieson to answer the first of them. The details of the investigation again I’ll refer you to Florida. Our understanding is that they did surveys both at the workplace, as well as in the community. And for the community -- 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 I’ll 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: Next question comes from Robert Lowes with MedScape Medical News. ROBERT LOWES: 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 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 tourism industry in Miami? TOM FRIEDEN: No. In fact, this is consistent with the CDC guidance we'd 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 there wouldn't be a technical or scientific basis to give a broader recommendation. We don't have evidence that there’s spread more broadly. We do know that all throughout parts of 30 states of the U.S., we have Aedes aegypti mosquitoes. 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 are 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 vector control efforts don't seem to be working as well as they ought to be. What is showing up in their traps? Mostly aedes aegypti? Is it anything else, and I don't think there's been any positive hits yet in terms of infected mosquitoes, and I have a follow-up question. TOM FRIEDEN: Thank you. They are using traps specific for Aedes aegypti and they are catching mostly Aedes aegypti. As far as we know they've not had any positive mosquitoes. And we don't expect that. It’s 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. You have been doing work looking at potential vectors for Zika and particularly whether some of the mosquitoes that are more prevalent in the United States could be common vectors. Are you seeing any signs that anything else is a potential problem? DR. LYLE PETERSEN: That work is ongoing. So far to date, they've been looking at Culex mosquitoes which are the ones that spread West Nile. We’ve found no evidence to date that the virus can be propagated in those mosquitoes. TOM FRIEDEN: We’ll 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, on the Friday call, the CDC, you were saying that there was no need to issue any sort of travel bans. And I’m wondering what has changed. 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. They are still seeing more Aedes aegypti mosquitoes (the mosquito that spreads this) than we had hoped. Second, the additional testing that 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 Friday. Because of that, today we advised pregnant women not to travel to that area. And we'll continue to work with Florida to look at the data every single day. Florida is releasing additional information on 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 basically have identified, as mentioned, ten 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. They’ve tested more than 200 people through these different investigations of local or 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, but we've been working closely with Florida for weeks on this and other investigations. And we recognize it's a situation that changes rapidly. This is what we've seen with Zika. We literally are responding daily. We work 24/7 to protect people. As soon as we get new information that affects how we give guidance, we will provide that new guidance. We have time for one last question. OPERATOR: Our last question comes from Tom Howell with the “Washington Times." TOM HOWELL: You mentioned you don't expect widespread transmission but you do expect possible sustained transmission in these localized areas. For people who hear that there won't be supposedly widespread infections swirling throughout the continental U.S. and those who doubt $1.9 billion number, can you explain why the $1.9 billion number is still the number that, you know, you feel is needed to combat this disease? TOM FRIEDEN: 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 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 terrible tragedy for that family. And also can cost $10 million 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. 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 to 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. Thank you once again for joining us. We’ll provide more updated information as we have it. Thank you. http://www.cdc.gov/media/releases/2016/t0801-zika-update.html

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Aug. 1, 2016 http://www.floridahealth.gov/newsroom/2016/08/080116-zika-update.html Department of Health Daily Zika Update Contact: Communications [email protected] (850) 245-4111 Tallahassee, Fla. — In an effort to keep Florida residents and visitors safe and aware about the status of the Zika virus, the department will continue to issue a Zika virus update each week day at 2 p.m. Updates will include a CDC-confirmed Zika case count by county and information to better keep Floridians prepared. There are two new travel-related cases today with one in Manatee County and one in St. Lucie County. Please visit our website to see the full list of travel-related cases. On Friday, July 29, the department confirmed Florida’s first local transmissions of the Zika virus in four individuals in Miami-Dade and Broward Counties. Three locations of interest were investigated based on where these individuals spent a majority of their time. Since the department began our investigation into possible local transmissions of Zika on July 7th, more than 200 individuals in Miami-Dade and Broward counties have been tested for the virus who live or work near the individuals that have already been confirmed with likely mosquito-borne transmissions. See breakdown of cases and testing numbers below. One case in Miami-Dade: 54 close contacts and individuals from the community have been tested with no additional positives One case in Broward: 70 close contacts and individuals from the community have been tested with no additional positive Two cases in the area of interest in Miami-Dade: tested 26 close contacts, one confirmed and three probable; 52 individuals from the community have been tested, six were positive but asymptomatic The department tested close contacts and community members within a 150 meter radius, the maximum distance that Aedes aegypti mosquitoes are known to travel. These community surveys are the first systematic assessment of individuals for possible asymptomatic Zika virus infection ever performed. Finding six asymptomatic individuals who were positive for Zika contributes to our understanding of the role these individuals may play in transmitting Zika. The department has conducted testing for the Zika virus for more than 2,300 people statewide. At this time, the department still believes active transmissions of the Zika virus are occurring in one small area in Miami-Dade County, just north of downtown. The exact location is within the boundaries of the following area: NW 5th Avenue to the west, US 1 to the east, NW/NE 38th Street to the north and NW/NE 20thStreet to the south. This area is about one square mile and a map is below to detail the area. This remains the only area of the state where the department has confirmed there are local transmissions of Zika. If investigations reveal additional areas of likely active transmission, the department will announce a defined area of concern. In the area where active transmission is occurring, the department continues door-to-door outreach and is gathering samples for testing to determine the number of people affected. Mosquito abatement and reduction activities continue. The department continues to work closely with CDC and, at the direction of Governor Scott, has requested a CDC Emergency Response Team (CERT) be deployed to Florida. The CERT team will consist of a vector control expert to provide guidance on local mosquito control measures, a laboratory professional to assist with rapid testing, a pregnancy birth defects registry expert to assist with tracking pregnancy outcomes and a risk communications professional to assist with messaging and outreach to target populations. CDC recommends that women who are pregnant or thinking of becoming pregnant postpone travel to areas with widespread Zika infection. Florida’s small case cluster is not considered widespread transmission, however, pregnant women are advised to avoid non-essential travel to the impacted area in Miami-Dade County (see map below). If you are pregnant and must travel or if you live or work in the impacted area, protect yourself from mosquito bites by wearing insect repellent, long clothing and limiting your time outdoors. According to CDC guidance, providers should consider testing all pregnant women with a history of travel to a Zika affected area for the virus. It is also recommended that all pregnant women who reside in or travel frequently to the area where active transmission is likely occurring be tested for Zika in the first and second trimester. Pregnant women in the identified area can contact their medical provider or their local county health department to be tested and receive a Zika prevention kit. CDC recommends that a pregnant woman with a history of Zika virus and her provider should consider additional ultrasounds. Additionally, the department will work closely with the Healthy Start Coalition of Miami-Dade County to identify pregnant women in the one square mile area to ensure they have access to resources and information to protect themselves. CDC recommends that a pregnant woman with a history of Zika virus and her provider should consider additional ultrasounds. Florida has been monitoring pregnant women with evidence of Zika regardless of symptoms since January. The total number of pregnant women who have been or are being monitored is 55. The Council of State and Territorial Epidemiologists and CDC released a new case definition for Zika that now includes reporting both asymptomatic and symptomatic cases of Zika. Prior to this change, states reported only symptomatic non-pregnant cases and pregnant cases regardless of symptoms. This change comes as a result of increased availability for testing in commercial laboratories. On Feb. 12, Governor Scott directed the State Surgeon General to activate a Zika Virus Information Hotline for current Florida residents and visitors, as well as anyone planning on traveling to Florida in the near future. The hotline, managed by the Department of Health, has assisted 2,480 callers since it launched. The number for the Zika Virus Information Hotline is 1-855-622-6735. The department urges Floridians to drain standing water weekly, no matter how seemingly small. A couple drops of water in a bottle cap can be a breeding location for mosquitoes. Residents and visitors also need to use repellents when enjoying the Florida outdoors. More Information on DOH action on Zika: On Feb. 3, Governor Scott directed the State Surgeon General to issue a Declaration of Public Health Emergency for the counties of residents with travel-associated cases of Zika. There have been 29 counties included in the declaration– Alachua, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Highlands, Hillsborough, Lake, Lee, Manatee, Martin, Miami-Dade, Okaloosa, Okeechobee, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Santa Rosa, Seminole, St. Johns, St. Lucie and Volusia – and will be updated as needed. DOH encourages Florida residents and visitors to protect themselves from all mosquito-borne illnesses by draining standing water; covering their clothing and bare skin with repellent; and covering windows with screens. DOH has a robust mosquito-borne illness surveillance system and is working with CDC, the Florida Department of Agriculture and Consumer Services and local county mosquito control boards to ensure that the proper precautions are being taken to protect Florida residents and visitors. On April 6, Governor Scott and Interim State Surgeon General Dr. Celeste Philip hosted a conference call with Florida Mosquito Control Districts to discuss ongoing preparations to fight the possible spread of the Zika virus in Florida. There were 74 attendees on the call. On May 11, Governor Scott met with federal leaders on the importance of preparing for Zika as we would a hurricane. Governor Scott requested 5,000 Zika preparedness kits from HHS Secretary Sylvia Burwell as well as a plan from FEMA on how resources will be allocated to states in the event an emergency is declared. On June 1, Governor Scott requested for President Obama to provide preparedness items needed in order to increase Florida’s capacity to be ready when Zika becomes mosquito-borne in our state. On June 9, Governor Scott spoke with Health and Human Services Secretary Sylvia Burwell and CDC Director Dr. Tom Frieden on Zika preparedness and reiterated the requests that he has continued to make to the federal government to prepare for the Zika virus once it becomes mosquito-borne in Florida. Governor Scott also requested that the CDC provide an additional 1,300 Zika antibody tests to Florida to allow individuals, especially pregnant women and new mothers, to see if they ever had the Zika virus. On June 23, Governor Scott announced that he will use his emergency executive authority to allocate $26.2 million in state funds for Zika preparedness, prevention and response in Florida. On June 28, the department announced the first confirmed case of microcephaly in an infant born in Florida whose mother had a travel-related case of Zika. The mother of the infant contracted Zika while in Haiti. Following the confirmation of this case, Governor Scott called on CDC to host a call with Florida medical professionals, including OBGYNs and physicians specializing in family medicine, to discuss the neurological impacts of Zika and what precautions new and expecting mothers should take. On July 1, CDC hosted a call with Florida medical professionals, including OB/GYNs, pediatricians and physicians specializing in family medicine, to discuss the neurological impacts of Zika and what precautions new and expecting mothers should take. More than 120 clinicians participated. On July 29, Governor Scott announced that the department had gathered enough information as part of its ongoing investigation into non-travel related cases of Zika in Miami-Dade and Broward counties to conclude that a high likelihood exists that four cases are the result of local transmission. The department believes that active transmission of the Zika virus is occurring in one small area in Miami-Dade County, just north of downtown. The exact location is within the boundaries of the following area: NW 5th Avenue to the west, US 1 to the east, NW/NE 38th Street to the north and NW/NE 20th Street to the south. Florida currently has the capacity to test 6,609 people for active Zika virus and 2,059 for Zika antibodies. Federal Guidance on Zika: According to CDC, Zika illness is generally mild with a rash, fever and joint pain. CDC researchers have concluded that Zika virus is a cause of microcephaly and other birth defects. The FDA released guidance regarding donor screening, deferral and product management to reduce the risk of transfusion-transmission of Zika virus. Additional information is available on the FDA website here. CDC has put out guidance related to the sexual transmission of the Zika virus. This includes CDC recommendation that if you have traveled to a country with local transmission of Zika you should abstain from unprotected sex. For more information on Zika virus, click here. About the Florida Department of Health The department works to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts. Follow us on Twitter at @HealthyFla and on Facebook. For more information about the Florida Department of Health please visit www.FloridaHealth.gov.

14 local cases + County Number of Cases (all travel related) Alachua 5 Brevard 8 Broward 55 Charlotte 1 Citrus 2 Clay 3 Collier 4 Duval 6 Escambia 2 Highlands 1 Hillsborough 10 Lake 1 Lee 6 Manatee 2 Martin 1 Miami-Dade 99 Okaloosa 2 Okeechobee 1 Orange 40 Osceola 18 Palm Beach 18 Pasco 6 Pinellas 7 Polk 12 Santa Rosa 1 Seminole 12 St. Johns 3 St. Lucie 2 Volusia 5 Total cases not involving pregnant women 333 Cases involving pregnant women regardless of symptoms 55 Lasted updated: Aug. 1, 2016 http://www.floridahealth.gov/diseases-and-conditions/zika-virus/index.html?utm_source=flhealthIndex

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County Cases Bell 1 Bexar 8 Brazos 1 Collin 2 Dallas 22 Denton 3 Ellis 1 Fort Bend 3 Frio 1 Galveston 1 Gray 1 Grayson 1 Hamilton 1 Harris 24 Lubbock 1 Medina 1 Tarrant 13 Travis 3 Val Verde 1 Williamson 3 Wise 1 Total 93 Dallas Pregnant Registry 12 Texas Preg Reg excl Dallas 29 Total 134