Public Health: An Inconvenient Truth

"Even if we had a fully credible warning of an imminent influenza pandemic, we wouldn't know what to do with it."  ----  Senior Official with U.S. Health and Human Services

 

Defeats the entire purpose of a "NORAD for infectious disease", doesn't it?  Indeed, the strategy writ large in our country is to build out capability in the area of medical countermeasures (vaccines, antimicrobials, etc), with the hope that we have covered all possible biological agent incursion events of all sources of attribution (natural, accidental, intentional).

During the 2009 H1N1 influenza pandemic, we discovered quickly that delays in countermeasure production and deployment of the H1N1 vaccine resulted in a situation of massive expenditure with precious little mitigation to show for. 

We are often asked by others "isn't the government already doing this?"  Specifically, "isn't CDC forecasting, providing early warning, to promote the use of such information to improve our nation's health security in a manner analogous to our National Weather Service?"

Unfortunately, the answer is no.  Strategic assessments, well-crafted forensic epidemiological studies and clinical guidelines, yes, but the production of data whereby any American is able to type a zip code in and retrieve an infectious disease forecast simply does not exist.  Surely, our public health system is among the best in the world for certain functions, but near-real time operational forecasting, situational awareness, and emergency response is not the forte of our public health professional community.

Take the policy of our National Oceanic and Atmospheric Administration (NOAA), which is the parent organization of our nation's National Weather Service:

NOAA will carry out activities that contribute to its mission, including conducting research; providing environmental assessments; collecting and archiving data; ensuring their quality; issuing forecasts, warnings, and advisories; and providing open and unrestricted access to publicly-funded observations, analyses, model results, forecasts, and related information products in a timely manner and at the lowest possible cost to users.

It is interesting to note that public health has a tendency to withold information until after a forensic investigation has concluded.  This is the byproduct of concern for maximal credibility when speaking to the public as a recognized authority.  Unfortunately, this operational hesitation comes at a cost: an advisory issued often after an event is well-recognized by the involved community.  Granted, an advisory issued regarding one community may be pre-event when viewed by an adjacent, as-yet uninvolved community.  But as has been demonstrated several times in this blog, public health's ability to communicate in an open, unrestricted, and operationally productive fashion that demonstratively contributes to community resilience is inversely proportional to the several features of an infectious disease event:

1. How fast the agent spreads;
2. How many hosts are affected;
3. Ease of clinical or laboratory recognition of the agent;
4. Clinically apparent disruption to the host;
5. Socially apparent disruption to the community; and
6. ... Other factors.

Operational failure is typically observed in public health agencies upon the appearance of a highly transmissible, difficult to diagnose, massively disruptive infectious disease event.  This should be obvious to students of infectious disease crises and disasters. So what is the current state of the art in anticipating and providing near-real time situational awareness for infectious disease events?

Those of a military mindset often look to Pearl Harbor as an example of warning failure that led to grave consequences for the United States (and the world).  A well-known public health analogy is the protracted recognition and warning of HIV-AIDS.  But other major warning failures in US history have occured as a repetitive pattern that has existed for as long as we have had a public health service, including:

• the 1889 influenza pandemic, which showed up in copious media reporting in Asia and Europe, yet did not result in a timely warning to the US

• the 1918 influenza pandemic, which likewise appeared in media reporting overseas long before its appearance in the US

• the 1957 H2N2 influenza pandemic, where lack of attention to publicly available Chinese media reports resulted in tremendous warnings delays:

The first reports to reach WHO were from Singapore early in May to the effect that an extensive outbreak of influenza was occurring and that it appeared to have been introduced from Hong Kong. Later, information was received that the epidemic began in continental China about the third week in February and according to Chu (1958) it originated in Kweichow Province between Kweiyang and Kutsing, which is in Yunan Province. In early March the outbreak had spread to Yunan Province and by the middle of March it had spread all over China. The virus was first isolated in Chanchung by Chu et al. (1957) and in Peking by Tang and Liang (1957) and it is clear that they recognized most of the important features of the virus which have since been described elsewhere. It is unfortunate that this information did not reach the rest of the world until the epidemic was already spreading widely. If it had we should have had two more months in which to prepare. [Society of Medical Officers of Health, 1958]

• the 1968 H3N2 influenza pandemic, where lack of attention again to publicly available Chinese media reports resulted again in tremendous warning delays:

We are dependent on a single newspaper report that the outbreak in Hong Kong was immediately preceded by an epidemic of acute respiratory disease in southeastern China. There is no information on the etiology of this outbreak in China but its close temporal relationship to subsequent events makes it possible that it was due to the Hong Kong strain. It will have escaped none of the members of the Conference that the 1957 pandemic first came to light in southern China, and the experience in 1968, though very tenuous, adds a little more information to the often-expressed hypothesis that strains of influenza virus which have the capacity to spread widely and rapidly often arise in that part of the world. Unfortunately contact between health authorities in China and other countries is even more difficult than in 1957 and it is impossible to obtain information on the possible origin or behavior of the epidemic prior to its appearance in Hong Kong. [WHO, 1969]

• the translocation and subsequent permanent ecological establishment of West Nile virus in the North America (1999), where initial warning signatures were ignored.

• the emergence of SARS in Asia, 2002, where our team documented on a log scale the number of publicly available Chinese media articles describing a grossly unusual infectious disease disaster in southern China months before any public announcement by WHO or CDC.

• the influenza vaccine mismatch of 2007, where thousands of advisories were issued to CDC that resulted in no warning to the American public.  Public health would rightly point out the parents of these dead children chose not to vaccinate.  However the better question to ask is whether these parents had a full and uninhibited right to the risk information in order to better inform their decision not to vaccine?

As of June 19, 2008, 83 deaths associated with laboratory-confirmed influenza infections have occurred among children aged < 18 years during the 2007--08 influenza season that were reported to CDC. These deaths were reported from 33 states (Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, Utah, Vermont, Washington, and Wisconsin). Among the 83 cases, the mean and median age was 6.4 years and 5.0 years, respectively; seven children were aged < 6 months, 16 were aged 6--23 months, 18 were aged 2--4 years, and 42 were aged 5--17 years. Of the 79 cases for which the influenza virus type was known, 51 were influenza A viruses, 27 were influenza B viruses, and one had co-infection with influenza A and B viruses. Of the 63 cases aged 6 months and older for whom vaccination status was known, 58 (92%) had not been vaccinated against influenza according to the 2007 Advisory Committee on Immunization Practices recommendations. [CDC]

• the 2009 H1N1 influenza pandemic, where escalating warning information was available for several weeks prior to public announcements issued by public health.

• CDC estimates that between 43 million and 89 million cases of 2009 H1N1 occurred between April 2009 and April 10, 2010. The mid-level in this range is about 61 million people infected with 2009 H1N1. 
• CDC estimates that between about 195,000 and 403,000 H1N1-related hospitalizations occurred between April 2009 and April 10, 2010. The mid-level in this range is about 274,000 2009 H1N1-related hospitalizations.
• CDC estimates that between about 8,870 and 18,300 2009 H1N1-related deaths occurred between April 2009 and April 10, 2010. The mid-level in this range is about 12,470 2009 H1N1-related deaths. [Ref] 
• This is more than six times the fatalities seen during 9-11.

• Here we deliberately ignore historical acts of biological warfare and terrorism, with associated gross delays in event signature recognition, warning, and mitigation.  The point being, Mother Nature has provided us plenty of examples without needing to invoke examples of political sensitivity.

 

So where is the NORAD for infectious disease?  Indeed, where is the demonstration of policy in public health equivalent to that of NOAA?  Where is the demonstrable embracing of forecasting as an invaluable instrument of proactive, cost-effective medicine? 

It has often been observed it takes the death of many in a tight geotemporal focus for a society to recognize the inadequacy of its cultural protections vis a vie 9-11.

How many more infectious disease crises or disasters must we observe before we overcome our affliction aka the Cassandra Syndrome?