Table 2.

Zika response building blocks and quotes

Building block	Quote
Health service delivery, Health Care and Testing	“At [the hospital], the way that it works now is that a woman is seen in the OB clinic, ‘Hello. How are you? You’re pregnant,’ and we have a separate phlebotomist downstairs in the outpatient lab where the pregnant woman doesn’t have to wait for her Zika testing so she finishes her clinical visit. She goes down a floor. She has her blood and urine collected and then she goes.”—Health Care
Health service delivery, Health Care	“Right now, under Early Steps, a child has to be Zika positive in order to be eligible for Early Steps or have [a neurological] disability like be born to a mother with Zika positivity and be microcephaly or have intracranial calcification or something else but they have to have one of those two things.”—Health Care
Health service delivery, Health Care	“A lot of these women don’t look to seek the care after birth because they think their babies are fine even if there is still a probability that something may happen down the line… they moved back to their country so we can’t really track them down there… other states in the US, or territories like Puerto Rico or Virgin Islands.”—Public Health
Health service delivery, Coordination	“… Once the tests are positive, then we try to see whether or not the pregnant woman has a provider on file so we can follow up with the provider…, or if they don’t have a provider, then we just go over what the results – what test came back positive. Try to explain what’s going on with the whole process and then if they don’t [have a health care provider], we tell them about Healthy Start. Then after that, we are the ones that refer the pregnant women…”—Public Health
Health Service Delivery, Testing	If they’re lucky that in an epidemic that had lasted more than, I don’t know, six months. To think that’s 18,000 pregnancies that should have been tested.”—Care Coordination
Health workforce, Training	“[Community Health Center] is another relatively low-budget access clinic…and they’ve been contacting me directly… if it’s an uninsured patient then we’ll deal with everything there. So, they’ve been probably my second greatest source of referrals from the community.”—Health Care
Health workforce, Training	“So we’re hoping some of that state… information money gets used [towards]… Educating providers, both pediatricians and obstetricians, and nurse practitioners.”—Health Care
Health workforce, Capacity	“They [CDC] have a local county health department initiative right now that they’re providing to have a CDC contractor go to the local county health department and are involved in whatever aspect of Zika that you’re interested in. We have different groups, and everyone picked outreach so we have funding.”—Surveillance
Health workforce, Training	“They’re [obstetricians] usually not fully aware of what the pediatric resources are at their hospital but the CDC recommends early access to pediatric infectious disease, pediatric audiology, pediatric neurology and head imaging of the infant. So, if they’re in a hospital where he or she is unsure if they can do an ultrasound and MRI of the baby before they’re discharged, the goal is to do all of this screening before discharge—because it’s been pretty obvious that if you just give the mom five different clinic appointments they’re just not going to go. It’s too much.”—Health Care
Health workforce, Training	“Because the main thing, when our fellows call them on the phone, ‘Please come back,’ they’re like, ‘My baby looks fine.’ Then they’ll say, ‘Well, I went to the pediatrician and the pediatrician also told me he looks fine or she looks fine.’ …we need to start reaching out to the pediatricians and start educating them that even though the baby looks fine and everything looks okay so far, they have to bring them back.”—Health Care
Health workforce, Training	“I’ve been going through every single provider’s office in [the County] and the toolkit that we give them has the algorithm for testing, when to test, and then what the test results mean and how to read the test results.”—Public Health
Health information systems, Infectious Disease Response	“…every time that they [FDOH Epidemiology Office] receive any patient from the doctors or the clinics or the hospital they know about, then immediately after, we will know about it. They will report it to us so we’d take the right mosquito control measure in the areas where these cases are.”—Mosquito Control
Health information systems, Public Education and Outreach	“They provided and continue to provide a kit that we hand to our mothers that has a repellent either lotion or cream. They also have the pamphlet where they get information about training and coverage, putting the long sleeves, using the condom. We also included in the bag, condoms. It’s a great teaching opportunity. We would hand them the bag with all these provisional things that really reiterated the message of protecting themselves while they were expecting in all those areas.”—Care Coordination
Health information systems, Public Education and Outreach	“The majority of the supplies that we’ve provided and will remain providing had been from the coalition. The Zika kits, probably 100 and we served well over a thousand women in – I’m sure more—in the last six, seven months so they had been providing us with like I said a household repellent. It has condoms. It’s a diaper bag. It also has the education for the Department of Health… and CDC guidelines, ‘This is what you need to do. You need to cover yourself. Use condoms,’ et cetera.”—Care Coordination
Health information systems, Public Education and Outreach	“Honestly, I think the [Healthy Start] coalition has really done a lot of the heavy-lifting like I said, providing resources for us to be available at the clinic…They also order and provided us [with] the resources for the repellents and other items. They also were the liaison between the Department of Health and us because we needed directions.”—Care Coordination
Health information systems, Public Education and Outreach	“In addition to that [distributing Zika kits], we had outreach in our health centers with the information sheet… We were giving those out at our health centers, and we were also distributing Zika kits to women that were our patients who came in and said they were going to continue their pregnancy.”—Health Care
Health information systems, Public Education and Outreach	“I feel like the tourists are probably getting the best messaging but trying to reach out to those other groups are a bit harder which is why it’s important to know where they are in your county so that you can try to [be targeting on] messaging whether or not it’s through like Spanish radio or Asian or Creole radio… We have to involve them [the Media] in anything really that’s going out to the public because they have the best way to do the messaging or the best way to get people’s attention.”—Public Health
Health information systems, Surveillance	“You have to consider there are two kinds of moving parts to this… They’re the Zika pregnancy registry, which is focused more on identifying pregnant women who have Zika and then following up on their birth outcomes, which is more the prospective approach. Then you have the retrospective approach, identifying children born with birth defects that are potentially related to Zika virus, they’re collecting information on them.”—Birth Defects Surveillance
Health information systems, Infectious Disease Response	"Their networks are these 700 providers as well as the APIC System [Association for Professionals in Infection Control and Epidemiology]. These groups are responsible for communication about all infectious disease including West Nile virus, Ebola, SARS, H1N1, and ZIKA is the same process. They receive their information from the state department and CDC. They send a blast fax to all their providers… This information is distributed to all doctors and their network…about 700 providers. They are at each of the hospitals—Jackson Memorial and UMH [University of Miami Hospital]." -Public Health (debrief)
Health information systems, Infectious Disease Response	“In terms of communication about ZIKA, this agency communicates the results they receive from CDC, the MMWR and the Department of Health through their network of providers.”—Public Health (debrief)
Access to essential medicines: products, vaccines and technologies	“Let’s say we do have a Zika vaccine. Who are you going to give it to? Everybody? Who’s going to pay for that? If you do have a vaccine and you use it as a true tool in an integrated program, you not only use ‘Where is the virus?’ which you can find out from the mosquitoes if you have good surveillance, and then you alert that neighborhood or that area.. ‘Go to the Public Health. Get a vaccine.”—Infectious Disease Research
Access to essential medicines: products, vaccines and technologies	The other thing of course is—that we need resources for—I don’t know how we can cut research when we’re dealing with a disease that for me is worse than HIV. Because with HIV, if mother is HIV positive, we have antiviral drugs. We can say, ‘Okay you can take these antivirals, and the possibility of transmission to your baby it can reduce to almost zero.’ If a mother has a Zika virus, nothing. No antivirals.”—Infectious Disease Research
Access to essential medicines: products, vaccines and technologies	“We look at the trap data in those areas and we see the average of mosquitoes caught on a weekly basis increases, but they trap more than—between five and ten, we go back and looked around to see where are these mosquitoes are coming from, but at this point, we are trying to be a little bit more proactive, so we’re still spraying larvicide by ground, by truck on a weekly basis.”—Mosquito Control
Health systems financing	“Because in the State of Florida this governor announced that the state will eat the cost of all of this Zika testing for pregnant women and that we could not afford to do any of this without that declaration like we would’ve been [unable to test] last summer if it wasn’t for that declaration.”—Health Care
Health systems financing	“But then the question I have for you is who’s going to get it? How are you going to vaccinate the entire population of Florida to prevent five microencephalic babies a year? Who’s going to pay for that?”—Infectious Disease Research
Health systems financing	“About half of the $13 million given to us by the Department of Health were for longitudinal neonatal studies so essentially enrolling the mom while she’s still pregnant or shortly after childbirth, for three years of continuity of care for the infant with compensation for travel and time and neurocognitive development, neuro imaging, neurology, ear, nose and throat—so basically above and beyond what the CDC is recommending for three years in both an investigation capacity and recognition that most patients can’t afford all of this.”—Health Care
Health systems financing	“And the state just got a big grant to do essentially coordination of services…Yes, $2.3 million for three years and they are supposed to be doing coordination…They want to build like a resource center so that, let’s say, in the practical world, South Miami or Mercy Hospital or Baptist has a case and they would contact this resource center who would direct it to the Zika response team for peds [pediatrics].”—Health Care
Health systems financing	“If they want to give us $3 million a year, which is about what we should have in our program, then we could do all these things wonderfully.”—Surveillance
Leadership and Governance	“CDC has put together guidelines and recommendations and what conditions are related to Zika…There’s specific codes, again, that are related to those conditions. Like microcephaly, there’s a code for microcephaly”.—Surveillance
Leadership and Governance	“Department of Health, speaking on both formally and informally referring pretty much every positive woman to me, sometimes for my care…they would have me explain the testing or at least give my perspective even if they stayed in my community.”—Public Health
Leadership and Governance	“I always say, ‘We have to protect Florida.’ Why? Because we have the same situation… of a lot of travelers, tourists.” – Infectious Disease Research