While the Zika virus is well documented in South and Central America, Florida, Puerto Rico, and the U.S. Virgin Islands, the mosquito-borne disease known to cause severe birth defects is also spreading in the U.S. territory of American Samoa, a group of islands in the South Pacific with a population of approximately 55,000.
And despite extensive prevention and education efforts by the U.S. Department of Health and Human Services, American Samoa may see even worse outcomes than expected due to economic and cultural factors, according to health officials and anthropologists.
There are currently 54 officially reported Zika cases in American Samoa, with at least 21 confirmed in pregnant women, and no cases of microcephaly yet, according to Scott Anesi, the territorial epidemiologist with the American Samoa Department of Health. However, the actual number of infections is likely to be much higher — approaching 1,000 since the outbreak — he said. This is due to the fact that not everyone with Zika reports symptoms or gets tested in the region, which has only one hospital and four health clinics. And because there are no local laboratories to test for the virus, results can take up to seven weeks to come back from U.S. labs.
"We're just now getting confirmed case results from the end of summer," Anesi told NBC News.
Since the outbreak began last year, health organizations have received over half a million dollars from the federal government to standardize strategies for educating populations at risk for the virus, which can also be transmitted sexually.
The strategies include the distribution of condoms and insecticides, peer-to-peer education efforts in villages, and offering free prenatal care across the territory. Within the last three months, local clinics have seen an 80 percent increase in women seeking care during their first trimester, Anesi said. All pregnant women who have sought care — now totaling 870 — are tested for the virus, given supplies of insecticide and condoms for the duration of their pregnancy, and followed closely by health officials. But many factors challenge the efforts to reach people outside of the prenatal healthcare system, Anesi said.
Prior to the complete subsidization of prenatal care this past summer, the majority of pregnant women in the territory only came to clinics during their third trimester. Women who were in their first trimester last spring when the outbreak began are just now beginning to give birth.
"We will get a good sense of the penetration of the virus shortly," Anesi said. "Microcephaly will be caught as soon as the baby is born, but the department is now also looking at previous births and screening babies regularly for a whole host of developmental issues that can be caused by the virus."
Furthermore, the public health advisory messages about prevention are not easy to carry out in the remote, import-based market. Mosquito repellant can cost as much as $8.50 per bottle, while the minimum wage is just $4 per hour, and average individual income is $10,500 per year, according to Anesi.
Prof. Michaela Howells — an anthropologist who teaches at the University of North Carolina Wilmington — has researched women's health in American Samoa and studied recent Zika prevention efforts by the federal government. She said that the Zika problem is not only compounded by poverty. Due to widespread conservative Christian values, public discussion of condom use and family planning is minimized in American Samoa. For instance, there is no sex education available in public schools.
"Access to condoms can also be challenging to groups of people who are expected to not be having sex, including unmarried individuals and those who are underage," she told NBC News. "There is concern that having condoms widely available will expose young people to inappropriate sexual information and encourage pre-marital sex."
In her work, Howells found that initial Department of Health efforts to distribute condoms over the past summer failed outright, and the supplies were left in the back rooms of clinics. She also noted that the first versions of educational materials about Zika transmission intended for use in local villages did not include images of Samoan people, were not translated into local languages, and explicitly described sexual behavior, so they were rejected by village leaders.
"The biggest issue was that the materials were not culturally appropriate," Anesi said. Working with the Department of Samoan Affairs, the Health Department eventually created an educational program that was approved by village leaders. But there are other issues that may prove unsurmountable.
If a pregnant woman has a confirmed Zika infection, she has no access to abortion, which is only legal in the territory if it will save the mother's life. American Samoan women can fly to Hawaii to terminate their pregnancies, but many cannot afford the trip.
If women in the territory start having babies with microcephaly and other Zika-induced symptoms, Howells predicts that the crisis could be exacerbated if public health officials do not incorporate knowledge of Samoan culture into treatment and education options.
"The reality is that we are about to have a large number of disabled children entering into systems globally, but we don't have the infrastructure for them," she said. "Samoans value large extended families, however, disabled children provide an additional social and financial stress on already stretched communities. . . this may disproportionately impact the mothers of affected children, leading to life-long economic deficits for these families." Anesi said the Health Department is working on this.
"We want to avoid stigmatization and are trying to make sure that those who are pregnant don't feel isolated, and we are building our social services and education capacity so that children affected by Zika will get education and assistance," he said.
Howells says that medical anthropologists have been advocating for the integration of culturally sensitive approaches to public health since the 1950s, but the Zika case in American Samoa demonstrates that this is still a pressing issue.
She and her colleagues are calling on public health organizations to work closely with local communities to build cultural competency in order to help Zika campaigns succeed. "Outside programs are most effective only once they have obtained the support of local medical officials, chiefs, and churches," she said.