Not If, but When: A Warning

Last month, my colleagues and I released a series of memos addressed to the Trump Administration and Congress describing the state of national and global health security and our recommendations on how to strengthen it. This is the second set of health security memos to an incoming administration that we’ve written. We write these transition memos to help new staffers navigate the complex biological threat environment, and to understand the programs and concepts that have been developed to address those challenges. As a result, the memos cover a wide range of topics, including public health and healthcare preparedness, the organization and funding of the federal health security enterprise, biosurveillance, community engagement, the security implications of synthetic biology, and others.

I’d like to focus here on a prediction that can be found in our memos, and has also been recently articulated by other subject matter experts. That is the judgment that this administration can expect to face a severe infectious disease emergency at some point during its tenure.

To wit (emphasis mine):

“If history has taught us anything, it is that the new administration is likely to experience at least one infectious disease crisis of significance. We have learned from the past decades that it is important to have strong global surveillance systems; transparency and honest communication with the public; strong public health and health care infrastructure, or capacity building efforts where needed; coordinated and collaborative basic and clinical research; and the development of universal platform technologies to enable the rapid development of vaccines, diagnostics, and therapeutics. We also have learned that it is essential to have a stable and pre-established funding mechanism to utilize during public health emergencies similar to a FEMA-like emergency disaster fund. What we know for certain is that emerging infections will continue to be a perpetual challenge, requiring the attention of all Presidents to come.”

Dr. Anthony Fauci, Director, National Institute for Allergy and Infectious Diseases

“Finally, the near and long term challenge most in need of a global response is that of emerging infectious disease. Terrorism and cyber threats have featured prominently in all three of the transitions on which I worked.  Most recently, in my transition meetings with my successor, I urged that the new administration will need to maintain a third focus when it comes to transregional threats that will keep people up at night: infectious disease.

It is a virtual certainty that the new administration will be challenged by some new pathogen, one that no wall will keep out. Ebola and Zika showed us pandemics need not have a malicious origin to take lives, cause panic, and drain resources. This will take focus, resources and precisely the sort of global cooperation that is difficult when countries feel alienated from American leadership. The Global Health Security Agenda, championed by the Obama Administration and now 50 countries strong, must be sustained. It requires United States investment and leadership to ensure that countries continue transparent, independent health assessments and are accountable for progress.”

Lisa Monaco, Former Assistant to President for Homeland Security and Counterterrorism and Deputy National Security Advisor

“It's not if, but when these events are going to occur again…We need to ramp up our preparedness.”

Dr. Peter Salama, Executive Director, Health Emergencies Programme, World Health Organization

“Each POTUS has faced outbreak crises: AIDS, SARS, Bird flu, swine flu, Ebola. Just a matter of time.”

Jeremy Konyndyk, Former Director, Office of US Foreign Disaster Assistance, USAID

“…it is safe to assume that one or more events that require a national-level response will occur in the near term. As a result, ensuring a high degree of public health preparedness should be a national priority.”

Matthew Watson, Dr. Jennifer Nuzzo, Matthew Shearer, Diane Meyer, JHSPH Center for Health Security

While I’ve highlighted just handful of examples above, I don’t think this is a particularly controversial position. Anyone with a passing familiarity with microbiology or epidemiology would probably agree.

A couple of things strike me as notable. First, the consistency and near-certainty of the message. While the occurrence of infectious disease outbreaks is highly stochastic, the sheer volume of recent, off-normal biological events - to include the 2001 anthrax attacks, biosafety lapses, and major epidemics or pandemics like SARS, H1N1 influenza, MERS, Ebola, Zika, and others - strongly suggests more to come.

Just why these events have been coming at such a rapid clip, and why we should expect more, can be explained by several different factors including environmental degradation, a changing climate, available and affordable international air travel, changes in human behavior and consumption patterns, the mutation rate of pathogens, and the occurrence of spillover events. In some cases, human failings such as malevolence or carelessness have come into play. For me, though, the most important contributing factor is that humanity is getting really good at recognizing cases and clusters of viral, bacterial, and fungal infections. We can now watch epidemics develop in real time, and we are increasingly on the lookout for emerging and re-emerging infectious diseases. The increasing speed and accuracy of surveillance and diagnostic systems makes it critical that we develop a more nuanced appreciation of the risks posed by a given outbreak or pathogen, both in public and in the halls of power.  Some rational setting between indifference and panic would be optimal. 

Second, this warning of outbreaks to come is being sounded by a diverse group of scholars and practitioners from both poles of the health security spectrum. Now, it’s important to remember that individual judgements are just that, and it’s understood that expert judgment is not infallible. But taken in aggregate, I would suggest that these statements can best be understood as a warning that should be taken seriously at the highest levels of our government.

That’s what we know. What we don’t know, and what is probably unknowable, is the source, scale, severity, and nature of the next infectious disease emergency. The past 16 years have seen naturally occurring outbreaks, intentional events that can rightly be characterized as attacks, and accidents.

To ensure that we’re able to meet the next threat when it inevitably arrives, strengthening our national and global health security posture should be a high priority for this administration.


My thanks to research assistant Ashley Geleta (@ashley_geleta) for her help in preparing this post.

2016 Gets its Very Own Bio-lapse

In mid-December, USA Today published an article by Alison Young entitled Emergency trainees mistakenly exposed to deadly ricin. In it, she reports that more than 9,600 trainees at the Federal Emergency Management Agency’s (FEMA) Center for Domestic Preparedness (CDP) located in Anniston, Alabama had been unintentionally exposed to a lethal form of ricin during a series of training exercises spanning a five year period. In response to this revelation, FEMA administrator Craig Fugate has already called for an investigation by DHS’s inspector general, and CDP has suspended all trainings involving toxic exposures.

Most importantly, there is no indication that anyone became ill following exposure to the ricin used during training, and students wearing proper personal protective equipment while working with the toxin. That’s the good news. It would have been a cruel irony for anyone to be harmed simply while honing their skills for this rewarding but uniquely dangerous calling. What follows are some initial reactions to this story.

Some background is in order. CDP is where the nation’s police officers, firefighters, emergency medical services providers, emergency managers, and healthcare workers gain the particular knowledge and experience needed to respond to a range of crises, including those of a CBRN nature. State and local responding agencies can send staff to Anniston for highly specialized training courses, such as the infection control and clinical course offered to US-based healthcare providers who deployed to West Africa to contribute to the Ebola response effort in 2014-15.

Second, a few observations about ricin. From the Center’s fact sheet:

Ricin toxin or ricin, as it is more commonly known, is a protein that consists of A and B subunits that can be extracted from the beans of the castor plant, Ricinus communis…The toxic effects of ricin are caused by its ability to inhibit protein synthesis. Ricin can be introduced to the body through inhalation of an aerosol, or through ingestion, injection, or infusion.

The mosaic nature of ricin’s composition is important to understanding what had apparently been going on at Anniston for the past 5 years. Per FEMA’s statements in the USA Today article, they thought their students were working with a powdered preparation of ricin’s A chain protein, which would have been much safer to work with while still generating positive results by environmental detection assays. Here is where things get (semi) interesting.

There are actually two chemically distinct lectins produced in castor beans, ricin and Ricinus communis Agglutinin (abbreviated “RCA”), which is significantly less toxic than ricin. To add to the confusion, at least one naming convention designates the whole ricin toxin “RCA60”. One might wonder whether CDP staff saw that they were receiving a product labeled “RCA” and interpreted that to mean “Ricin Chain A.”

Needless to say, there should be a thorough investigation in this case, as the question of responsibility appears to have devolved into a finger pointing exercise between FEMA and the contractors responsible for providing the agency with the product they ordered.

Regardless of confusion over names, labels, purchase orders, and intentions, many people may quite reasonably be wondering why first responders should have anything to do with ricin toxin in the first place. The answer relates to a worrisome but under-appreciated trend in the post 9/11 era: the skyrocketing occurrence of white powder incidents. First responders are called to thousands of these events per year, the vast majority of which events turn out to be hoaxes. But, every once in a while, a bored college student, romantic rival, or would-be assassin figures out how to formulate and use at least a crude preparation of the real thing. As a result, every suspect powder has to be treated as potentially harmful until field-based detectors, confirmed by laboratory diagnostic tests, indicate otherwise.  Make no mistake, the high frequency of these white powder incidence makes bio-detection as vital for some local first responders as CPR.

In order to be sure that responders can handle these white powder incidents safely, there is no substitute for rigorous training. To protect themselves and the public, local first responders have to be able to discriminate fake threats from real ones. The myriad detection technologies available to first responders vary significantly in their ease of use, sensitivity, specificity and turn-around-time. In other words, they can be difficult to use properly, and thus the need for training with live agents – to ensure that equipment works properly and first responders can accurately run them and interpret the results.

Unavoidably, there is the issue of optics. Ms. Young understandably links the Anniston incident with prior examples of biosafety lapses by federal biodefense programs. Let’s review. Last year it was live samples of anthrax inadvertently mailed by a Department of Defense lab (a story that may actually say as much about the incredibly hardy biology of B. anthracis as it does the sufficiency of inactivation protocols). The year before that, it was the unexpected discovery of viable variola virus in an FDA freezer on NIH’s campus in Bethesda, MD. In that same year, CDC made headlines with an unexpected exposure of staff to B. anthracis. So… not great. And now, 2016 has a bio-lapse of its very own.

Once you get past the headlines though, it’s less clear what should be done about that less-than-stellar track record. In each instance, the value of the underlying program to national and global health security is beyond question. What’s more, each of those incidents took place in very different operational and organizational contexts, so a one-size-fits-all policy fix isn’t likely to materialize. Finally, because of the amount of agent CDP was working with (reportedly less than 70mg), they were not recognized as a regulated entity under the CDC’s Select Agent Program, this instance should not be interpreted as a regulatory failure.

That said, it is not my intention to downplay the significance of this unusually long running event. Had a health impact occurred resulting from exposure to a pathogen or toxin, the results could have been tragic. Additionally, should the public or their legislative representatives begin to perceive more risk than benefit from federal biodefense programs, their continued existence could be called into question, to the detriment of our national health security.

What this series of unfortunate events underlines is the need for continued, systemic commitment to - and flawless execution of - biosafety and biosecurity practice at every governmental agency engaged in these efforts. In addition, the field could probably benefit from an increased level of scientific inquiry into how to enhance biosafety at the institutional and national levels. Whether or not those steps are taken before the next lapse takes place is an open question. 

Tonight’s Top Story: Ebola and the News Media

When the first few cases of Ebola came to the US in 2014, it seemed as though it was impossible to watch or read the news and not hear about the disease.  At first, news coverage of Ebola rose in response to the return of media personnel diagnosed overseas.  Then news coverage increased greatly after the diagnosis of the first case on American soil in late September, 2014.

Most of us can agree that the intense public and media reaction to the limited number of cases in the US was unwarranted when considering the actual risks involved in the situation.   In fact, many actions were put forth, out of an abundance of caution, which were unnecessary and counter-productive, such as border closures and excessive quarantines. But what was the source of this reaction? Was the news media responsible for stoking people’s fears? What messages were people receiving about the risks of and policy responses to the occurrence of Ebola in the United States? 

To investigate this, colleagues and I set out on a news media content analysis, reading over 1,200 news articles from 12 news sources spanning the time frame from the beginning of July through the end of November 2014. Each time we read an article, we searched for a set of messages relating to risk and policy using a coding instrument that had been piloted on a separate set of articles. We used Paul Slovic’s risk perception framework to determine if some messages would likely have increased perception of risk or decreased perception of risk. Our methods and findings can be found here and here.

We found that nearly every article in our sample (96%) had at least one risk-elevating message while approximately half (55%) had at least one risk-minimizing message. However, although skewed towards risk elevating messages, news coverage from the main stream news sources we analyzed did not seem to report on Ebola in a hyperbolic or overly irresponsible manner – for instance, we found relatively few mentions of use of Ebola as a bioterror weapon or the suggestion that, once introduced, the disease could not be stopped in the US.  In fact, messages about the ability to interrupt transmission in the US were more frequent, when directly compared to messages about an inability to interrupt transmission. It may have been that the news media played a smaller role in hyping the Ebola outbreak than expected, and the nature of the disease itself played a stronger role than was originally recognized in increasing public concerns.

Perhaps most importantly from a risk communication perspective, it was clear that public health policy messages were frequently eclipsed by more controversial messages.  The most frequent policy messages we found were focused on isolation (47%) and quarantine (40%), which were often confused with each other (isolation is the separation of someone who is ill from those who are not sick while quarantine is the separation of someone who may have been exposed to a disease from those who have not been exposed). In contrast, one of the more central public health response policies – assigning different levels of risk and associated movement restrictions for potentially exposed individuals – was rarely found (5%). This difference could be due to the newsworthiness of controversial issues – quarantine was controversial while a measured public health approach was not.  As a result, Americans may have gained a skewed or incomplete understanding of the response activities that public health agencies were putting into place in the midst of the crisis.

At the end of the day, the news media played an important role in delivering messages about Ebola to the public and will no doubt perform a similar role in future outbreaks.  Although our study methodology prevents us from drawing conclusions about the public’s understanding of the risks posed by Ebola and associated response activities, it allows us to gain a more granular understand about the messages the public may have been exposed to via the news media. Although the news media frequently mentioned risk-increasing messages, some of the most inflammatory messages were not found as frequently as expected (though they may have been present in more “fringe” news sources that were not included in our analysis). However, we did find that communication of important scientific principles and policies can struggle to gain traction in the face of controversial issues. In the future, public health communicators should keep these factors in mind when communicating via the news media and emphasize the scientific underpinning of our understanding of the disease and appropriate responses. 

Unnecessary Blindness: Hospitals Preparing for Pandemics

When the inevitable next pandemic influenza virus emerges, hospitals will be challenged to meet the requirements of a large cohort of individuals with varying degrees of illness. These patients will likely strain all the resources of hospitals including personnel, medical supplies, pharmaceutical supplies, and medical equipment. Because of the uncertainty regarding the magnitude and the nuances inherent in such events, it is a difficult task for a hospital to right-size its planning. Several tools exist, however, that have been developed to help provide estimates of supply needs including one developed by my colleagues: Panalysis.

To provide a real-world test of Panalysis, a team of us from the Center, Interdisciplinary Solutions, the University of Pennsylvania’s Wharton School, and the Mayo Clinic performed a stress test of the Mayo Clinic’s emergency pandemic supplies using various modeled scenarios. The result of that exercise was just published in the American Journal of Infection Control.

In this paper, my colleagues and I developed several different pandemic influenza scenarios of varying severity and, using Monte Carlo simulation, juxtaposed it against the specific features of Mayo Clinic and its patient catchment region in multiple iterations. Through the simulations, we could generate demand curves for certain supplies such as oseltamivir, gloves, and ventilators allowing insight into what types of demand would be expected for each of these items during various pandemic scenarios.

Using these demand curves, a facility like the Mayo Clinic could determine what level of preparedness they determined it prudent to invest in and compare current stockpiles to desired levels. For example, ventilator inventories could be maintained to be sufficient to meet the demands expected for 75% of the pandemic scenarios generated and an attendant cost generated. Similar cost-benefit analysis could be applied to N-95 respirators, courses of oseltamivir, or any other relevant item.

Every hospital will face unique challenges based on their location, services offered, catchment demographics, and size. Each will also have a differing risk calculus for preparedness and, instead of approaching this vital issue in an off-the-cuff/back-of-the-envelope manner tools such as Panalysis could be implemented to help bring rigor and quantification to these decisions allowing them to be evaluated in a manner much more fitting to their importance.

Zika: Where We Stand Now

The month of October has finally arrived, bringing to a close what has been one of the hottest summers on record on the East Coast. As Halloween and Thanksgiving draw nearer, so too does cooler fall weather, bringing with it a decline in U.S. mosquito populations. These mosquitoes, particularly those of the Aedes aegypti species, have caused widespread concern throughout the U.S. and abroad, as Zika virus infections have emerged in numerous countries. The continental United States saw its first locally transmitted Zika case in Florida in late July, and additional locally-acquired cases have been occurring since then.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), has been at the forefront of the U.S. fight against this disease. Last month, I had the pleasure of attending a colloquium at Georgetown University’s O’Neill Institute for National and Global Health Law led by Dr. Fauci, which also featured other experts in policy and infectious diseases including Dr. Stephen Morrison from the Center for Strategic and International Studies, and Dr. Daniel Lucey from the O’Neill Institute. While a wide variety of topics were addressed, there were two themes that continually emerged during their discussion.

1. Funding. Public health practitioners cannot effectively fight a disease that has been declared a public health emergency of international concern by the World Health Organization with an empty bank account. While awaiting funding from Congress, NIAID had to shift money earmarked for other deadly diseases such as malaria and Ebola, and the National Institutes of Health had to pull money from other areas to fund Zika activities and research, including vaccines, treatment and vector control.

On September 28, nearly eight months after President Obama’s initial request for $1.9 billion dollars in emergency supplemental appropriations to fight Zika, Congress finally passed a funding bill. While the funding bill, at $1.1 billion dollars, is 800 million dollars short of President Obama’s initial funding target, it is a move in the right direction. Now, it is critical that these funds are distributed promptly to aid in vector control, to invest in research to better understand the effects of the virus on fetuses and children, and to aid in diagnostic technologies and vaccine research.

The idea of a public health contingency fund was brought up multiple times by the panelists, and could potentially alleviate the need to grapple for funding as an epidemic is unfolding. This would greatly enhance preparedness for infectious disease threats, allowing medical countermeasure research to commence quicker and provide resources for public health departments who are in the throes of responding to an emergency.

2. Preparedness. Zika virus is not the first emerging infectious disease to challenge our national and global health security, nor will it be the last. Rapid urbanization, high-speed global travel, climate change and deforestation are just four of the many factors that are driving the emergence or reemergence of severe infectious diseases. Given this reality, we should not be surprised when they occur, and have robust plans and programs in place to mitigate their worst effects. This more proactive response prioritizes disease surveillance, rapid microbiological characterization, medical countermeasure development, and support to the local health sector. As Dr. Fauci stressed, infectious diseases know no borders, and epidemics outside of the U.S. should be just as concerning as ones within our own borders.

As cooler temperatures approach, it is likely that the number of Zika virus cases will decline. It is important, however, that the lessons learned from the Zika virus outbreak are applied to future infectious disease outbreaks, and we’re able to shift to a more proactive response when the next disease inevitably emerges.

Status Report: Zika Virus in the United States

As of early October, there have been 105 locally-acquired cases and 3,712 travel-associated cases in the United States, and thirteen cases of Guillain-Barre Syndrome (GBS). In the U.S. territories, there have been 24,118 locally acquired cases, and 83 travel-associated cases reported, with an unknown number transmitted through sexual contact. Additionally, there have been 39 cases of GBS in U.S. territories. Florida is the only state thus far to have reported locally acquired cases, and along with New York, also makes up the greatest percentage of travel-associated cases.  Puerto Rico, unfortunately, accounts for nearly all of both travel-associated and locally acquired cases in the U.S. territories, and is easily bearing the greatest burden from the Zika outbreak.

The National Institute for Allergy and Infectious Diseases NIAID is currently developing multiple vaccine candidates for Zika prevention. The candidates include a DNA-based vaccine, a live-attenuated vaccine, an investigational vaccine using genetically engineered vesicular stomatitis virus, and a whole-particle inactivated vaccine. In late September, the candidate DNA vaccine entered phase 1 clinical trials, which will determine its safety in human subjects. DNA vaccines are a relatively new immunization technology where a sequence that encodes an antigen of interest is introduced and expressed, hopefully leading to an immune response. The early progress of this and other Zika vaccine candidates is encouraging, however it will likely be years before a vaccine is available to the public.

Prevention has largely included efforts to control the mosquitoes that vector Zika, including aerial spraying of insecticides and getting rid of standing water. Individuals are also encouraged to protect themselves from mosquito bites by using insect repellent and wearing long-sleeve shirts. Since Zika is now known to spread through sexual contact, safe sex practices such as condom use are also being promoted.

Finally, in a recent publication in JAMA, Dr. Tom Frieden, the director of the CDC, provides a more in-depth update on the Zika outbreak, which he calls an “unprecedented emergency” due to its ability to cause birth defects via a mosquito bite.

The future of Zika virus is uncertain. While impending colder temperatures will almost certainly decrease transmission in most of the continental US, it remains a possibility that Zika will persist in over-wintering Aedes mosquitoes. As a result, continued research in medical countermeasure development should remain a priority. The U.S. public health and healthcare sectors should also continue to prepare to support the children and families who have been, and will continue to be, impacted by this virus. 

Remembering DA Henderson in Stories and Tributes

The world lost a great man today.  We have posted a summary of DA Henderson’s incredible life and achievements here, but that is only a glimpse into the story of his extraordinary life.  We wanted to use this blog post to invite others who knew him, worked with him, or met him along the way to share their stories, tributes, fond memories of DA as one way of honoring him and sharing what people found to be so special about him.  I will start. 

DA’s professional life is almost beyond description.  From the time he was a young doctor in public health, he was drawn to big problems and never stepped away from a challenge.  In the 1960s, he was expected to fail as newly named Director of the smallpox eradication program, but more than a decade later – with the help of more than a million people along the way – he succeeded.  Using the structures and programs built in that effort, DA became a global champion of the Expanded Program on Immunization, a childhood global immunization effort that has saved countless lives around the world.   He changed the way schools of public health approached their mission. He brought public health thinking into the highest halls of government for Presidents Bush and Clinton. He started talking about emerging infectious diseases and deliberate biological threats in ways that were important and courageous, and that galvanized a cadre around the country and the world to commit themselves to these issues.

It was his conviction and leadership that led me into working on health security and public health.  His calls to action, the clarity of his voice and reasoning, and his friendship all persuaded me to join him in this work and to help him start an organization focused on these issues 18 years ago.  As of the start of this summer, he continued to be an ongoing important presence and voice in our Center that helped shape all of our thinking.   

In the time that I was lucky enough to know him and work with him, I saw him provide his counsel to public health leaders around the world dealing with their crises of their day.  I saw him accept almost every invitation to teach that came his way.  I saw him wade into controversies without a moment’s hesitation when he believed something needed to be done or a course needed to be corrected. 

It wouldn’t be surprising if someone as accomplished as DA became too busy to deal with the next generation.  But DA was the opposite.  He sat down with any aspiring student or colleague considering a life in public health.  He was generous beyond belief with his time and his energies. 

DA had the constant support of his incredible wife Nana and his kids who he adored. They were all on a tremendous journey along with him.      

We will miss DA terribly.  We hope his principles and experience and his teaching will live on in some small ways in all of us, and we know his work and his thinking will influence the rising generation of public health leaders in the US and around the world

If you have stories to share, tributes to offer, specific memories to pass on, we’d like to collect them below in the Comment section of this blog.  We will share them with DA’s family and friends, and it will help all of us to hold on to a bit more of him.  Please feel free to add to the Comment section directly.  

Pitt CCM Grand Rounds: Biosecurity, Medicine, and National Security - A Guided Tour

On August 17, Dr. Amesh Adalja delivered the University of Pittsburgh’s Department of Critical Care Medicine’s grand rounds. During his “guided tour” of biosecurity, national security and medicine, he discussed various threats to public health, including bioweapons and emerging infectious diseases; and how the UPMC Center for Health Security is working to ensure communities are resilient should an epidemic or disaster arise. To concretize the type of projects the Center undertakes and illustrate its relevance to critical care medicine, he discussed how to best plan for a large number of patients experiencing acute respiratory distress syndrome (ARDS) in the context of an avian influenza pandemic.

This grand rounds was live-tweeted by the Department of Critical Care Medicine, and we’ve compiled these Tweets to provide readers with a quick overview of Dr. Adalja’s tour of this important facet of medicine and public health. 

Update: Video of Dr. Adalja's talk is now available.  

Don't cancel the Olympics because of Zika

This opinion, by Tara Kirk Sell, was first published in the Baltimore Sun on June 6th.

With the Zika outbreak in the Americas raging and the growth of scientific support about potential birth defects from maternal infection, some in public health have called for the 2016 Summer Olympics in Rio to be postponed or moved. As a fellow public health researcher and a pregnant Olympian swimmer and silver medalist at the 2004 Olympics in Athens, I have a close-up perspective on both sides of this issue and believe this opinion does not balance the risks appropriately.

Importantly, there simply isn't enough evidence at this point to support a large-scale, intrusive public health action that will devastate so many people. While Zika can cause severe outcomes in some, the vast majority of people who are infected will not experience symptoms. Newly emerging scientific evidence has shown clear connection between Zika and birth defects, but there are simple protective actions that can be taken to reduce the risk of infection. Often, decision makers justify extreme public health interventions "out of an abundance of caution" and a desire to remove all risk from a situation. But these arguments overlook any real consideration of the costs of taking these unwarranted actions, which are often high for those people who are affected by them.

Read More:

Public Perception of GM Mosquitoes in Florida

As we approach Memorial Day weekend, summer is just around the corner, as is mosquito season. There has been a lot of discussion about what that means for public health this year as the Zika virus spreads in South America and the Caribbean and infected travelers return to the US. Most experts agree that we will likely see at least some local mosquito-borne transmission of this virus in the States this summer because we’ve seen similar outbreaks of dengue and chikungunya in years past.

Yet despite early warning of Zika arrival and our recent experiences with mosquito-borne outbreaks, little additional investment has been made here to support mosquito control, and Congress is currently balking at providing emergency funding to support Zika preparedness and response. Actually, most mosquito control districts in the US have faced drastic budget cuts over time or have been de-funded completely within the past few decades. This had allowed mosquitoes to proliferate, relatively unchecked in temperate areas of the country. For instance, the Aedes aegypti and albopictus species of mosquitoes, which transmit Zika, dengue, chikungunya and Yellow Fever, have expanded their range geographically to cover much more of the US than was previously thought.

Now, with the specter of Zika approaching, and no vaccine or treatment likely to come for many months or years, mosquito control is our best and only available option to address this problem right away. Yet, mosquito control isn’t easy. Even in places like Florida and Hawaii, where investment is relatively robust, there are other barriers to reducing Aedes mosquito populations and preventing disease transmission. Eliminating breeding is difficult because the mosquitoes can breed in very small amounts of water and in hidden locations. In addition, mosquitoes are beginning to become resistant to some insecticides and larvicides, rendering these control measures less effective than ever before. In response to these difficulties, there are a number of approaches being considered and tested around the world including new insecticides, public awareness campaigns, and introduction of sterile (genetically modified) mosquitoes to outcompete and thus reduce mosquito populations.  

One genetically modified Aedes aegypti mosquito, created by Oxitec, is being considered by the FDA for a field trial in the Florida Keys. However, this effort has been delayed, primarily due to public resistance to releasing the mosquito. We were interested in learning more about how the residents of the Key West neighborhood think about this issue.

In order to find out more, our group fielded a survey to the affected neighborhood in Florida last summer (before Zika had raised its ugly head). The goal of our study was to get a better understanding about local knowledge, attitudes, and beliefs regarding GM mosquitoes, and to gain insight into more effective approaches to community engagement surrounding mosquito control and disease reduction efforts. Our results provide a pre-Zika baseline of community attitudes toward GM mosquitoes, that is, to the best of our knowledge, unique in the rapidly growing scientific literature on the Zika virus.  

What we found was that among residents who responded, there was indeed significant opposition to GM mosquito use. Reasons for this opposition included general concern about GM mosquitoes, but also specific worries that GM mosquitoes could pass on modified genes to other mosquitoes, people, or animals; that introduction of these mosquitoes could have unforeseen and potentially harmful effects on the ecosystem; and that use of GM mosquitoes could lead to introduction of other GM products into the community. Many of the concerns expressed by residents have been countered with data and information from Oxitec and the Florida Keys Mosquito Control District (FKMCD), but residents were still not convinced. It is clear that a sustained dialogue with the community regarding the safety and efficacy of GM mosquitoes needs to occur. If and when GM mosquitos are introduced, the community needs to understand and be comfortable with the potential benefits, risks, and uncertainties.

When we examined opposition to GM mosquitoes more closely, we also found that both women and people who had never had personal experience with a mosquito-borne disease like dengue, were significantly more likely to oppose GM mosquitoes, indicating that the perceived risks of GM mosquito use in those groups outweighed the perceived risks of mosquito-transmitted diseases.

Now that Zika is becoming a major issue of concern, we think that public perception and attitudes toward GM mosquito use may be changing. So, this study is also valuable in providing baseline information from which to evaluate any changes in attitudes. With concern about health effects from Zika widely publicized in the US, risk perception has increased, and residents may be more likely to accept GM mosquito use than they were last summer. For example, a recent nation-wide survey by Purdue University indicated that a majority of surveyed Americans support the use of GM mosquitoes to control Zika in the US.

Follow-up studies to understand how community engagement efforts can be better designed and how risk perception influences community acceptance of new interventions like GM mosquitoes are in the works!

Reforming the Biological and Toxin Weapons Convention’s S&T Review Process

Editor’s Note: This guest post to the Bifurcated Needle was written by Amanda Moodie. Ms. Moodie is a Research Analyst at the National Defense University’s Center for the Study of Weapons of Mass Destruction, and was selected as an Emerging Leader in Biosecurity Fellow in 2015.  

As diplomatic conferences go, Preparatory Committee meetings for the Review Conferences of the Biological and Toxin Weapons Convention (BWC/BTWC) are generally rather dull. At quinquennial Review Conferences, States Parties review the operation of the Convention; the Eighth Review Conference, to be held in Geneva from November 7th to the 25th, 2016, will allow States Parties to take into account any relevant scientific and technological developments and assess the state of implementation of the Convention. The Preparatory Committee meeting, or PrepCom, gives delegations the opportunity to discuss the organizational aspects of the Review Conference, such as the Conference presidency, the distribution of posts of Chairs and Vice-Chairs of the subsidiary bodies among the regional groups, and the draft Rules of Procedure. This year marks a departure from the usual procedure, in that two PrepCom meetings will be held; the second meeting, scheduled for August, will “provide an opportunity for States Parties to consider comprehensively all provisions of the Convention,” while the first PrepCom, which took place 26-27 April, would work on “general exchange of views and the organizational aspects of the Review Conference.” Most of the substantive discussion that can help build consensus and explore ideas, in other words, won’t take place until later in the year. As a result, the first PrepCom was largely unexciting to all but the most die-hard multilateral negotiation wonks.

One PrepCom development, however, did catch the attention of BWC-watchers. Since 2006, the Preparatory Committee has requested the BWC’s Implementation Support Unit (ISU) to prepare, among other documents, a background information paper on “new scientific and technological [S&T] developments relevant to the Convention, to be compiled from information submitted by States Parties as well as from information provided by relevant international organizations.” This year, States Parties suggested that the S&T paper, as well as a background information document on relevant developments since the last Review Conference in other international organizations, should be dropped from the list of requests. The public response from BWC experts from the NGO community was not overwhelmingly positive:

It’s understandable that BWC experts are concerned about the absence of an S&T paper as background material for the RevCon. In order to make sure that the Convention functions appropriately and continues to serve its purpose of banning the development and production of biological weapons, representatives of States Parties need to stay informed about potential scientific developments that might make it easier for anyone to acquire such weapons, or even alter our understanding of what such weapons might be. Not every State Party has the capacity to carry out such reviews itself, and the ISU’s background paper ensured that all delegations were on the same page with respect to S&T developments prior to the RevCon – at least in theory.

The stated reason for the elimination of the S&T paper was the burden it was placing on the ISU. Early in the PrepCom this year, States Parties had upped the burden on the organization by requesting it to prepare two new background information documents, in addition to the eight papers it’s prepared for RevCons in the past. Some of the requested papers are compilations based on information submitted by States Parties or on previous RevCons’ Final Documents, but others require the ISU to carry out original research. Moreover, even the compilations require time and effort from the ISU, which is severely understaffed and will also have other work to do in preparation for the Review Conference. The S&T papers produced at the last two RevCons were compiled from information submitted by States Parties and international organizations. However, several States Parties not only provided details to the ISU on relevant scientific developments, but also prepared their own working papers which repeated the same information. Additionally, many States Parties did not receive or read the ISU’s paper before the RevCon and therefore did not hear about key scientific and technological developments in advance, which made it difficult for them to take those developments into account when reviewing the Convention.

So the ISU, which already has far too much work, was supposed to complete a paper that duplicated effort already being put forth by many States Parties and that other delegations likely wouldn’t read in time to put it to use. For these reasons, the S&T paper “was not widely regarded as a useful tool” [1] and was dropped. This is not ultimately a bad thing. Nor does it necessarily mean that the BWC will fail to take S&T developments into account during the treaty review process. In fact, there is significant support among States Parties to reform the S&T review process and figure out a better way to provide input to the Review Conferences on significant developments. Doing S&T review in a diplomatic treaty context is very difficult. The biological sciences are evolving at an incredibly rapid pace, and it will be tough for the Convention to keep up, even if reviews are carried out more frequently than every five years. Plus, it’s hard to identify which topics are actually relevant for the Convention. Diplomats do not always have sufficient scientific background to understand certain scientific advances, much less to grasp their potential implications and identify what questions need to be asked about their impact on the BWC.

Yet despite – or because of – these challenges, most delegations seem to understand the importance of the S&T review issue, and their working papers and comments in the exchange of views portion at the PrepCom suggest that they are prepared to reform it and make it more effective. The elimination of the ISU’s paper may be a sign that this has already begun: States Parties have already started to take a critical look at the S&T review process and eliminate redundancies or extraneous steps, with a view toward making it more efficient.



1 - Richard Guthrie, “[27 April 2016] The Preparatory Committee concludes its first session,” BioWeapons Prevention Project, PrepCom Report 13 (1 May 2016).