Johns Hopkins Center for Health Security Teams with NTI and the Economist Intelligence Unit to Develop a Global Health Security Index

We are very excited to announce that thanks to generous support from the Open Philanthropy Project and the Robertson Foundation, our Center is working with the Nuclear Threat Initiative (NTI) and the Economist Intelligence Unit (EIU) to develop a Global Health Security Index.

The mission of the index is to encourage progress towards a world that is capable of preventing epidemics of international impact (either natural, accidental or deliberate) from arising, or, should, prevention fail, respond quickly to contain them.

In the first phase of this project, our team is focusing on developing a framework (i.e., the value, principles, attributes, and major components) to assess and compare countries’ levels of health security. To help inform the development our framework, we are convening next month an international expert advisory group. Once we’ve developed our framework, we will begin the process of assessing, collecting, and analyzing data on a country-by-country-basis. 

Below we explain in more detail why we’ve embarked on this important project.

Why try to measure global health security?

Recent infectious disease outbreaks, such as the ongoing Zika virus outbreak, the Ebola outbreak in West Africa, and the spread of MERS-CoV in the Middle East, continue to show us that when individual countries experience difficulties detecting and effectively containing the spread of infectious disease outbreaks, they can quickly threaten the health, security, and economies of countries across the globe. The increasing frequency of events that threaten global health security illustrates how now, more than ever, there is a strong global need for collective action to bolster all countries’ health security capabilities.

Some measures have been taken by the World Health Organization (WHO) and more recently through the Global Health Security Agenda (GHSA). Although these are worthwhile, important initiatives, they have some limitations that an index could address.  

In 2005, updates were made to the International Health Regulations (IHRs) to improve countries’ abilities to detect, assess, notify, and report public health emergencies of international concern (PHEICs). Among the modifications, the revised IHRs created a set of 8 core public health capacities that countries must develop. To help countries assess their progress, the World Health Organization created a list of indicators for development of the IHR core capacities. But lack of funding, lack of political will, and a myriad of other factors have slowed implementation of the revised IHRs.  By its implementation deadline in mid-2012, approximately 80% of the 194 WHO member states had not reported implementation of the core competencies required under the IHRs. The results of those countries that do report are publicly available.

Recognizing the lack of progress toward implementation of the IHRs, the Obama Administration in early 2014 announced the launch of the Global Health Security Agenda. The initiative, which has since attracted the participation of more than 50 countries, attempts to establish common goals and methods to reduce the spread and impact of infectious disease by strengthening countries’ abilities to prevent, rapidly detect, and effectively respond to disease outbreaks. Participating countries have developed commitment packages and related targets under the GHSA.

The WHO recently launched an effort that is complementary to the goals of the GHSA. In developing the WHO IHR Joint External Evaluation (JEE) tool, the WHO has created a framework and process by which countries can measure their capacities to implement the IHRs. The JEE tool provides a standard metric by which countries can, on a voluntary-basis, assess their current baseline capacities and measure future progress toward full development of IHR capabilities to prevent, detect, and respond to public health threats, whether they are naturally occurring, deliberate, or accidental. Though the passage of the IHRs required countries to conduct self-assessments of their IHR capacities, the JEE enables countries to sign up for external evaluations by their peers. It is this peer-to-peer aspect that seems to be attractive for countries. Those involved in the JEE process have reported that countries that have volunteered to undergo a JEE have found the exercise to be helpful to their own planning effort. The positive reviews of the JEE process have spread, and countries continue to volunteer to undergo a JEE.

The GHSA and the JEE are important steps toward increasing accountability and transparency for countries’ efforts to improve their current global health security capacities. As we have written before, the international community—including the current US Administration--should continue to do all it can to support these efforts.

But the GHSA and JEE process alone will likely not fully address the need to motivate improvements in global health security. More work is needed to encourage those countries who have not yet signed up for the GHSA to participate. And work will be needed to ensure that all countries agree to undergo a JEE and—most importantly—take meaningful action to improve their scores in the areas that the JEE identifies as needing improvement.

Finally, the determinants of a country’s global health security are not entirely in the hands of the health sector. Larger political factors—such as land use policies and the presence of terrorist groups--can influence a country’s risk of experiencing an outbreak or bioattack. Societal factors, such as government corruption, social stability, and basic infrastructure, can be important determinants of how ably that country can contain the event before it spills across its borders.  These factors, while important determinants of global health security, are not incorporated into existing frameworks like the GHSA or JEE.

Why an index?

For the reasons articulated above, we think more work is needed to identify trends promoting global health security and to examine underlying conditions that contribute to or detract from favorable health security conditions. Metrics also are needed to identify areas in greatest need of improvement and to create political incentives for health security investments. A global health security index that is informed by international expert judgment, measured by a nongovernmental entity, and made publicly available could highlight current needs and add momentum to existing global health security efforts.

In preparation for this work, we have spent almost two years researching this topic and have learned that indices can be important tools in measuring and motivating progress. There is much evidence in the literature that national and international indices are influential in affecting government decision making. Policymakers tend to rely on these tools because decision-making processes that rely on indices can be presented as efficient, consistent, legitimate, transparent, scientific, and impartial. They also are relatively easy for the public to interpret.

Social science researchers have determined that indices tend to motivate policymakers to respond via three complementary mechanisms. First, indices can influence governments through the creation of international pressures (e.g., credit-rating agencies may respond to a country’s ranking in an international corruption index). Second, they can influence domestic political pressures (e.g., via mobilization of advocacy groups). Even the anticipation of negative publicity can prompt governments to review and modify domestic policies. Third, indices can have reputational effects on individuals or groups of policymakers and can motivate change through peer pressure.

We also have direct, favorable experiences in creating an index related to this topic. For several years our center director, Tom Inglesby, has been involved in the creation of the National Health Security Preparedness Index, which measures US states’ progress in preparing for, preventing, and responding to potential health incidents. Tom will bring to our team his experiences in developing and refining the NHSPI, which is now in its fourth iteration.

Why this team?

This effort will be jointly led by our Center and NTI, and developed with help from EIU.

NTI works to protect our lives, environment, and quality of life now and for future generations. They work to prevent catastrophic attacks with weapons of mass destruction and disruption (WMDD)—nuclear, biological, radiological, chemical, and cyber. Founded in 2001 by former U.S. Senator Sam Nunn and philanthropist Ted Turner, NTI is guided by a prestigious, international board of directors. Sam Nunn serves as chief executive officer; Des Browne is vice chairman; and Joan Rohlfing serves as president.

Economist Intelligence Unit (EIU) is the research arm of The Economist Group, publisher of The Economist. As the world’s leading provider of country intelligence, it helps governments, institutions, and businesses by providing timely, reliable, and impartial analysis of economic and development strategies. Through its public policy practice, the EIU provides evidence-based research for policymakers and stakeholders who are seeking measureable outcomes, in fields ranging from gender and finance to energy and technology. It conducts research through interviews, regulatory analysis, quantitative modeling, and forecasting, and it displays the results using interactive data visualization tools. Through a global network of more than 350 analysts and contributors, the EIU continuously assesses and forecasts political, economic, and business conditions in more than 200 countries.

NTI and EIU make for expert partners on this project, as we intend to build on their experience and success in developing the NTI Nuclear Security Index.  Created in 2012, this first-of-its-kind resource is designed to encourage governments to take actions and build confidence in the security of their nuclear materials. Now in its third edition, the NTI Index is recognized as the premiere resource and tool for tracking progress on nuclear security and identifying priorities.  

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: http://www.baltimoresun.com/news/opinion/oped/bs-ed-olympics-zika-20160605-story.html

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!