Health Security 2014: Morals of the Story, Part 1

The year read like an infectious disease manifesto:  antimicrobial resistance on the rise in the US and around the world; perennial health threats of mumps, measles, and whooping cough afflicting different parts of the US; MERS continuing to simmer in the Middle East and H7N9 in China.  Americans learned about new infectious diseases in their midst or just over the horizon --Enterovirus D68 and Chikungunya.   Ebola, the most alarming of all new epidemics this year, tore through West Africa, and led to a small number of cases and a great level of national concern in the US.  On top of this litany of epidemics came a series of safety incidents at top national labs. There was the accidental exposure of CDC personnel to anthrax; the discovery of live smallpox samples in an FDA lab; an erroneous shipment from CDC of a dangerous influenza strain; and now this week, a potential laboratory exposure to Ebola at CDC.  Meantime, debate continued about the safety and value of research intended to create highly pathogenic, highly transmissible strains of viruses.  If people didn't think they had a reason to tune in to health security at the start of this year, they sure have reason to now.  

Preparedness for potential health security emergencies typically receives relatively little attention in the 24 hour news cycle (and the national budget). It’s in our human and political nature to respond to the burning fires at hand, while leaving preparedness for future, uncertain crises for another day.  But if there is one constructive thing that came out of the repeated health shocks of 2014, it’s the fact that health security couldn’t be ignored.  The past year showed, among other things, the importance of hospital preparedness and public health response, scientific research and development that leads to effective diagnostics and countermeasures, and reliable communications between health officials and the public.

If the year read like an infectious disease Odyssey, the lessons learned can be read like Aesop’s Fables:   

Expect the unexpected

At the start of 2014, no one working on infectious disease response or health security related issues would have predicted that Ebola would emerge as the most important epidemic in a generation.  Few would have anticipated that CDC (and more recently, the UK) would have struggled with a string of laboratory accidents.  Did anyone expect an emergent enterovirus would start causing paralytic illness in children in the US?  And so on.  No doubt there will be unexpected health security challenges in 2015 mixed in with the continuing problems already in view.  We need professionals, institutions, and systems in place that are strong and nimble enough to rise to meet the challenges. Are we prepared for all of this now? We aren’t, but we can continue to get better and to track our progress.  To have experienced people and strong organizations in place will require sustained resources that don’t rise and fall crisis to crisis.    

It’s thrifty to prepare today for the wants of tomorrow

One reason Ebola has devastated Liberia, Sierra Leone and Guinea is the terrible state of the health care infrastructure in those countries.  These systems were both very poor in resources and had far too few health care workers for national needs.  Another reason that the Ebola epidemic got going in the first place was because of the terrible delays in getting an actual diagnosis.  The disease spread from village to village in Guinea with no one knowing what was going on.  Unreliable technology then led to the misdiagnosis of cholera, which slowed down response ever further.  These and the many other signs of the fragile West African health system should help us understand that similar conditions exist in many other parts of the world.  It is the collective interest of the global community to improve the health care and outbreak response capacity of those countries that have the least resources.  One sign that countries are paying attention to this is the Global Health Security Agenda (GHSA), an effort of over 40 countries that are taking specific steps to improve the worldwide capacity to prevent, detect, and respond to infectious disease threats that are sure to astonish us in the future.  The more we help create critical health care infrastructure through efforts like the GHSA, the less we will suffer Ebola- like events of tomorrow.   

It’s one thing to propose, another to execute

When even our some of our best labs in the country experience accidents, it’s evident that accidents can happen in any lab.  This experience of accidents at CDC shows us there is more work to do in building good biosafety culture and programs.  Biosafety programs need to be supported by leaders and funded accordingly.  Institutional Biosafety Committees need to have the expertise and resources they need to do the work they are asked to do.  Scientists need to be able to report concerns and mistakes without fear of reprisal.  Research into infectious disease pathogens will continue to be critical for discovering new vaccines, medicines and diagnostics.  Overall very few laboratorians are seriously sickened or hurt in US labs.  But there is a very small area of research that poses special risks -- research intended to create highly pathogenic, highly transmissible strains of viruses. This area of research needs to be examined with great caution, as is now occurring during the research moratorium for that work.  While in the planning and proposal phase, biosafety risks may appear to be fully controlled and manageable, in the execution phase, human error or other lapses can occur.