The Haiti Epidemic Advisory System (HEAS) is scrambling now to issue an Emergency Appeal, as cholera has most certainly reared its head yet again, this time in Grand Anse with 445 cases and 59 fatalities.
The Haiti Epidemic Advisory System (HEAS) is scrambling now to issue an Emergency Appeal, as cholera has most certainly reared its head yet again, this time in Grand Anse with 445 cases and 59 fatalities.
Exerpt from an upcoming publication:
From 1978-82, an epizootic of anthrax appeared in Rhodesia in the context of the Front War, where the minority European-controlled government fought a losing engagement against Maoist- and Soviet- backed African forces. Ultimately, they lost but not before South African-supported Selous Scouts engaged in biological and chemical weapons development. It is believed these activities in Rhodesia and similar incidents in Namibia were a research and development prelude to the South African Project Coast.
A documented 10,700+ human cases and an untold tens of thousands of cattle deaths were documented in Rhodesia at the time covering an estimated 200,000 km2. There were of course multiple unusual, non-routine epidemiological features documented at the time, not the least of which consideration of the prior baseline of case reporting in Rhodesia:
Figure 1. National level baseline reporting of human anthrax cases in Rhodesia from 1926-1977.
An astounding shift in epidemiological pattern upon the onset of this infectious disease disaster (i.e. an IDIS Cat 5), where the above statistics were recorded at the national level. The below was recorded at the provincial level and at a single hospital, respectively.
Figure 2. Midlands Province, Rhodesia: documentation of human anthrax cases.
Figure 3. Number of hospitalizations and fatalities due to anthrax, Beatrice Road Infectious Diseases Hospital.
The transmission intensity at Beatrice Road was such that they saw all clinical forms of anthrax: cutaneous, inhalational, gastroenteric, septic, and meningitic. These are photographs of some of the victims (credit: JCA Davies):
Many notable anthrax experts provided their opinion of this event being a "perfectly natural" epizootic in the context of a collapsed veterinary infrastructure during the Front War. We disagree. Details to follow in an upcoming publication.
One of the strongly suspected perpetrators who worked with the Selous Scouts- a man we interviewed on several occasions- was bludgeoned to death this year by unidentified assailants.
The recent, ongoing controversy about genetic experimentation with pathogens of high potential consequence for global health raises serious questions about our global capability and capacity to 1) detect events associated with accidents of biological technology ("biotechnology"); 2) recognize those signatures; and 3) issue timely warning of such phenomenon to the world in a transparent process free of political tendencies to withold information.
First, please refer to prior posts on the difference between signature detection, recognition, and warning. Here we define capability as the inherent knowledge of how to execute the analytic discipline of biological signature detection, recognition, and warning; and capacity as the global load factor for capability, where obviously a single analyst cannot possibly watch the entire planet.
In regards to the recent reports of deliberate genetic experimentation with H5N1 virus, the root question that should have been asked by the media and anyone astutely watching the controversy is why did the US National Institutes of Health (NIH) authorize the expenditure of US taxpayer funds for the experiment in the first place?
Funding from NIH does not happen magically. One has to respond to a Request For Proposals (RFP) with a formal proposal that includes a detailed description of the experiment that is to take place and the justification for that experiment. There is a rather uncomfortable question to be asked of Dr. Fauci and his staff that goes something like this: "Were you aware of the nature of the experiments about to be conducted by these researchers using US taxpayer funds before the experiments were actually executed?"
However unlikely, it is a well-documented fact that the more infectious an agent, the more likely it is to infect laboratory workers. In this particular case, the probability for an infection to occur was likely neglible, but there nonetheless. And trust that the world's public will not accept any excuse should the unthinkable have happened: a laboratory accident that triggered a community outbreak. The terrible juxtaposition of the highly improbable with the unthinkable consequence again raises its head.
So let's play this scenario out: what is the global capability and capacity to pick up on these kinds of events? This question is asked because, if we are to believe then the NIH failed to recognize the risk in conducting these experiments in the first place, then how fast do we honestly think we as a global community would have recognized the "oops" should the virus have infected one of the laboratory workers... a worker that went home that night to expose others? How many chains of transmission would have occurred before it would have been picked up by an astute physician or public health analyst? How fast would the dots have been connected to trace back to this being an engineered H5N1? How fast would seed stock have been secured for vaccine production companies? How fast would those companies be able to grow vaccine stock and execute distribution?
The answers are very, very bad and uncomfortable. Let's give some additional data points:
1. The discovery of Marburg virus in Germany, 1967. This was a laboratory accident involving a previously unknown lethal, transmissible virus. Exposed laboratory personnel went home to their families and in turn exposed them. Note the initial diagnostic confusion, calling the disease "yellow fever", then "monkey disease":
Aug 23, 1967 Sept 13, 1967
2. Laboratory Accident Historical Surveys
It is useful to review the historical records of laboratory accidents. Figure 1 displays the top diseases and pathogens that infected and killed laboratory workers in the United States from 1930 to 1950, the results of the most comprehensive survey of its kind, conducted by Sulkin and Pike in 1951.
Figure 1. Laboratory infections [a] and case fatality rates [b] by agent / disease for civilian laboratories in the United States from 1930 to 1950. This is a sampling of the original data. The entry titled “encephalitis” refers to infections by Western (1), Eastern (1), and Venezuelan (11) equine encephalitis viruses and Russian Far East encephalitis virus (1). Infections were due to other pathogens as well.
Figure 1 represents a sampling of the total list of agents involved in reported laboratory infections. Other agents and diseases included:
All manner of infectious agents and their byproducts such as toxins have essentially posed risk for laboratory workers not protected by Biological Safety Cabinets, negative pressure rooms, proper handling protocols, or vaccine. During the time period covered by the survey, there were few vaccines or antibiotics to mitigate exposure. It is believed the survey was a gross underestimate of the true number of infections. There was no systematic reporting mechanism to report laboratory infections in the United States at the time, as is the case now.
Singh provided an updated perspective based on Pike’s survey in 1976, as shown in Figure 2.
Figure 2. Laboratory infections [a] and case fatality rates [b] by agent / disease for civilian laboratories in the United States based on updated assessments by Pike in 1976. This is a sampling of the original data.
When considering biological weapons programs, new hazards were introduced relating to handling of aerosols, mass production, and deployment testing of live agents. Figure 3 provides summaries of laboratory infections in Fort Detrick personnel during the years of the active United States biological weapons program (1943-69).
Figure 3. Laboratory infections during the years of the active American biological weapons program (1943-1969), showing annual infections due to anthrax [a], tularemia [b], brucellosis [c], Q fever [d], and Venezuelan equine encephalitis [e]. In the case of Venezuelan equine encephalitis, an ineffective live attenuated vaccine candidate was responsible for a number of infections. Use of Biological Safety Cabinets began in 1950. Anthrax vaccine was available beginning in 1952. Tularemia vaccine was available beginning in 1958. Brucellosis research was decreased beginning in 1953; no vaccine was available. A vaccine for Q fever was available in 1965. The TC-83 live attenuated Venezuelan equine encephalitis vaccine was available in 1963.
Other agents and diseases were responsible for laboratory infections at Fort Detrick such as:
Aside from the obvious increased risk for a laboratory accident being related to handling live agents, there are several risk characteristics worth noting:
3. The epizootic of Venezuelan Equine Encephalitis in Venezuela and Colombia, 1995. This was a significantly disruptive epidemic involving an estimated 100,000 people that peaked at the same time as a seasonal peak in direct, non-stop air traffic to Florida in 1995. This was yet another example of warning failure due to failure to detect, recognize, and warn. Most poignant was the hypothesis the epizootic was due to a laboratory accident- a hypothesis posed only years after the fact.
CAP, the American Association of Bioanalysts, the American College of Family Physicians and the American College of Physician Services all sent proficiency testing surveys containing one or more samples of A/H2N2 to approximately 6,500 labs in the United States. Proficiency testing panels containing A/H2N2 samples were also sent to laboratories in Belgium, Bermuda, Brazil, Canada, Chile, France, Germany, Hong Kong, Israel, Italy, Japan, Lebanon, Mexico, Saudi Arabia, Singapore, South Korea and Taiwan. The World Health Organization has informed the Ministries of Health in these countries.
5. The still-open case of possible ongoing transmission of polio vaccine-derived virus type 1 in Haiti. Here translocation of a suspect case to North Carolina went completely undetected by North Carolina's public health officials, CDC, and PAHO/WHO. The context of social outcry over the suspected accidental introduction of cholera by the United Nations to Haiti provided a strong disincentive for officials to carry out a complete investigation. The still-open question is whether deployment of Sabin / oral live attenuated polio vaccine in Haiti resulted in the escape of what may be, in essence, an accident of biotechnology out in Haiti's ecosystem continuing to recombine with native enteroviruses. The lack of a credible investigation into this question remains a concerning point of accountability for PAHO and CDC. Even more concerning is the multi-million dollar industry interest in continuing to produce, distribute, and vaccine people in extremely vulnerable areas of the world with this agent that has a well-documented nasty habit of causing transmissible disease.
These of course are but some of many examples and observations related to the concern of the proliferation of biological technology. Accidents should be expected as human-driven processes and procedures are fallable by nature. And politics certainly have, do, and will cloud situational awareness.
As discussed in depth in a prior post, our discipline shares substantial historical and methodological parallels with meteorology. Here we discuss an event impact evaluation system based on peer-reviewed findings of the nearly 100-year old disaster sociology community and the tornado Fujita Scale, including the new "enhanced" version (EF Scale).
Our prior efforts to quantify "biological event evolution" resulted in an approach destined for a full revision and re-imagining: the Wilson-Collmann Scale (WCS):
The WCS was based on a similar meteorological-inspired premise but the underlying model was derived from a single anthropological study that examined the social impact of epidemics, our own "expert" input, and later a prospective sample of open source media articles. The word expert was placed in quotes because this preceded operational experience that eventually encompassed tens of thousands of biological events in nearly every country on earth. The shortcomings of the approach were 1) limited understanding of the broader anthropological and sociological literature, 2) limited operational experience monitoring indicators of infectious disease events, and 3) limited experience monitoring infectious disease events as they manifest in different cultures under different conditions of social sensitivity.
Similar to software versioning, we were compelled to redesign this model several times until a more operationally valid approach was achieved. The most profound development was a complete abandonment of the WCS and a reanalysis that used nearly 100 years of peer-reviewed literature from the disaster sociology community.
Depending on the culture and location in the world, we recognized there was a baseline level of resiliency in relation to whatever cultural protection was in place. For the developed world, this would represent healthcare workers working within an established medical and public health infrastructure. It is the transition between what is viewed as simply an "event" from the perspective of the local community to transitioning into a crisis or disaster. It is key to note this process is predicated by local recognition of a problem interpreted to be some form of a threat to the individual(s), organization(s), or the community at large. The underlying principle is the interplay between local public expectation for a given level of cultural protection in relation to how well that expectation is perceived to have been met under the circumstances. It is this evolution of community awareness that becomes important when recognizing a deteriorating situation involving an infectious disease.
The Infectious Disease Impact Scale (IDIS)
Our current operational framework for assessing the sociological impact of acute, disruptive infectious disease events is the Infectious Disease Impact Scale (IDIS):
Category 0. Unreported infectious disease event
Daily, routine infectious
diseases are handled at this level, and provision of warning about
these diseases is not deemed 'relevant'.
Non-routine infectious disease may also manifest as a Category 0 infectious disease event, implying the "astute clinician" in the local community network has not raised the concern something unusual was observed in the clinic, and nothing unusual was noted in local public health information feeds. This is the bleeding edge limitation of disease surveillance, where the first case of unusual infectious disease is often missed.
Typical examples include a case of influenza-like illness, non-specific rash, or uncomplicated febrile illness seen by a healthcare provider.
Category 1. Reported infectious disease event
The typical Category 1 infectious disease event reported by a community reflects a sensitivity to public health or medical significance. No other significant features indicative of immediate public health or medical infrastructure impact, public anxiety, or civil unrest triggered by the event are noted.
Examples include report of a chickenpox outbreak, limited norovirus outbreak, or a single case of methicillin-resistant Staphylococcus aureus (MRSA).
Category 2. Infectious disease event associated with routine organized response
Category 2 events often reflect locally well-known diseases that nevertheless generate a demand for organization-level time-sensitive action. This action is local routine.
Examples include routine community action for seasonal diarrheal disease or seasonal influenza. It is important to note non-routine infectious disease may present as a Category 2 event, particularly when it shares similar clinical features with routine disease. The classic example is the appearance of pandemic influenza in the context of normal seasonal influenza, as was observed in April 2009 with pandemic H1N1. Early indicators were difficult to distinguish because the level of impact had not reached "critical mass" to allow social recognition of the event as a threat. Indeed, it is highly likely pandemic H1N1 was transmitting in Mexico well before April 2009, undetected. Thus, the non-routine may present as routine.
Category 3. Infectious disease event associated with non-routine organized response
Category 3 events are essentially the beginnings of a community crisis. The operational definition of a crisis we are working from is the following:
An infectious disease event becomes a
crisis when there is a
recognized requirement for time-sensitive, non-routine organization-level decisions
that may affect a local community’s activities of daily living. It is
common such decision-making falls within the organizational roles and
responsibility of a public health institution than a public or private
or individual healthcare provider.
This becomes a community level decision-making activity in
where there is no public health capacity. - Wilson, 2009
It is important to note Category 3 events may be associated with organized response features without significant broader social disruption, as evidenced in a Category 4 event.
Examples of this type of event include a new vaccine-drifted influenza type A variant that appeared before an updated vaccine could be made available to the public. Another example is the 1999 introduction of West Nile virus to the United States, after recognition of the event to represent a public health threat. In this category it becomes important to understand the differences between organized response seen in public health versus medical care such as that provided by a hospital. Monitoring both is crucial.
Category 4. Infectious disease event associated with social disruption
Category 4 events highlight when organized response has occurred, yet significant social disruption has been documented. The operational definition of social disruption we are working from is the following:
Social disruption [of community vital processes] refers to the process where a community moves from a given level of integration towards disintegration. -Wilson, 2009
Coleman’s (1966) original theory of community integration proposed “vital processes” of a community that “keep it alive as a community and prevent its disorganization”. These processes included:
- education of children
- religiously related activities
- organized leisure activities
- unorganized social play of children and adults
- voluntary activities for charitable or other purposes
- treatment of sickness, birth, death (healthcare)
- buying and selling of property
- buying consumable goods (food, etc.)
- saving and borrowing money
- maintenance of physical facilities (roads, sewers, water, light)
- protection from fire
- protection from criminal acts
It is well recognized infectious disease events may impact a community to the point of straining various aspects of these vital processes. Category 4 events may be associated with significant strain of multiple community vital processes without inducing community disintegration, which is the indication of a Category 5 event.
Examples of Category 4 events include the 1957, 1968, and 2009 influenza pandemics and the introduction of Chikungunya to India in 2006.
Category 5. Infectious disease event associated with disaster indicators
The operational definition of a disaster we are working from is the following:
An infectious disease crisis becomes a “disaster” when crisis mode decision making by public health officials or institution fails to control the situation, either from an informational or response perspective and substantial social disruption associated with features of community disintegration occurs as a result. -Wilson, 2009
This is the typical modern day end-point of social strain experiences when cultural protections fail and individuals of a community physically abandon their dwellings or those vital processes necessary for community integration. Note this is distinct from prior terminology used to describe the Wilson-Collmann Stage 4 biological event. In that description, "social collapse" was used to describe an end point, however this terminology is typically used by sociologists and anthropologists to describe the fall of Rome, disappearance of Easter Island's civilization, and the fall of the Incas. In other words, the collapse of a civilization. Social collapse certainly is an arguable end-point, however practical use of this consideration is limited to the point of being academic. Operationally, the more appropriate term is "community disintegration", as it reflects what is usually observed today on a global scale.
concepts of integration and
disintegration are not absolute: each community is associated with a
balance of factors that promote integration and disintegration. Disasters
tip this balance towards
disintegration. This concept therefore encompasses more than simply
health response capacity but a broader social context. -Wilson, 2009
Category 5 infectious disease events are classically observed as the so-called "panic evacuations", which is a misnomer. Observations for years has instead suggested people migrate out of an area of perceived high threat in a manner that attempts to preserve the family unit and other close social ties. It is often observed these individuals attempt to return to their homes. Thus, a Category 5 event typically represents transient community disintegration.
Examples include outbreaks of Ebola hemorrhagic fever in Africa, occasional abrupt appearances of cholera in IDP camps in Africa, and measles in Africa. We have also seen the 2009 H1N1 influenza pandemic induce Category 5 conditions among indigenous peoples in South America. The key is the intersection between the infectious disease event and violation of cultural protections to the point of inducing community disintegration.
Category 6. Infectious disease event associated with apocalyptic indicators
This is a largely hypothetical category that acknowledges the exceedingly rare reporting of community disintegration that has progressed to the point of people deciding to either commit suicide or succumb to doomsday feelings where they have dug graves and lie in them to await death. This type of social behavior has been reported in the anthropological literature only rarely among tribes who live in the most austere conditions, isolated from other communities, experiencing a serious epidemic.
We have not observed this type of event in our years of experience.
Operational Use of the IDIS
The IDIS is a model that serves as a guide to understanding the impact of acutely disruptive infectious disease events through the lens of disaster sociology. Up to this point, event descriptors of infectious disease events have focused on use of terms like "outbreak" and "epidemic". This is problematic in the operational setting when valid epidemiological data is often sparse or unreliable. Here we consider a different perspective that focuses on the interface between an infectious disease hazard and indigenous vulnerability. This then helps the warning analyst maintain a sense of perspective when attempting to understand which event out of thousands in the world deserves priority attention.
As with the staging of hurricanes and tornadoes, the frequency of Category 1 through 5 events declines dramatically the higher up the scale one goes. Further, the frequency of seeing higher category events varies not only by pathogen involved but by culture and associated indigenous cultural protections. Over time, we have seen there are baselines to such events, where the concept of what is considered "routine" and "expected" is challenged. This is analogous to describing risk due to earthquakes among communities that exist on fault lines, or recognition of certain states in the USA that experience higher frequency of tornadoes, where regular occurrence of such crises may be a baseline onto themselves.
Use of the IDIS requires an experienced analytic viewpoint to make judgment calls during the assessment process often in an environment of uncertainty. Attempts to categorize an infectious disease event may be challenged not only by uncertainty but also exposure of indigenous socio-economic inequities. It is well recognized that crises and disasters can often trigger political agendas or social outcry that may provoke civil unrest. Depending on the context, some infectious disease events begin as seemingly innocuous Category 1 or 2 events but later reach a higher categorization due to civil unrest that is less related to actual disease transmission effects but rather public perception. In other words, it becomes just as important to pay attention to the epidemiological features of an infectious disease event as the social context because the endpoint of disruption to the community may be as severe.
We have found the IDIS to be operationally practical especially when dealing with austere environments such as post-disaster Haiti, where formal medical surveillance is compromised. If access to credible epidemiological data is compromised, then there is a tendency to hesitate both in warning the public and responders as well as making the decision to execute a response. The IDIS offers an alternative approach to monitoring the infectious disease situation in a given area that may not have a robust infrastructure to support comprehensive epidemiological investigation.
As a final point, it should be noted the IDIS does not function as a mechanism to flag unusual events unless a comprehensive local baseline is well understood. There are other procedures for flagging events early in the evolution process as looking "unusual" that will be discussed in a later post.
In a recent article by Sprung et al in the journal Intensive Care Unit, the European Society of Intensive Care Medicine presented their summary recommendations for intensive care unit triage during an influenza epidemic or mass disaster. I offered a response to the authors based on our experience during the emergence of pH1N1 in Mexico:
I read your paper titled “Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster“ with great interest.
Attached please find a paper we published a couple of months prior to the H1N1 pandemic. We provided warning of the Mexico crisis to CDC and WHO and later created a near-real time situational awareness feed for the Society of Critical Care Medicine and the Critical Care Medicine- and Virtual PICU Listservs (CCM-L and vPICU) during the subsequent pandemic waves.
Your recommendations were spot-on except for one crucial point: an adequate early warning system for intensive care units. Infectious disease crises and disasters must be detected, warned, and proactively acted upon by those members of the medical community most impacted. I have also attached the experience of Vancouver versus Toronto during SARS- a tale of cities that presents an important perspective about the value of forewarning.
It was long our considered assessment the emergency department-intensive care unit axis of a hospital in developed nations represents the single most important part of the medical infrastructure. And most specifically, it is the intensive care unit we were most concerned about. This reasoning was due to
James M. Wilson V, MDDownload Vancouver Response to SARS
The evolution of the nature of the threat is nowhere more pronounced than in the area of biological weapons. A revolution in biotechnology continues, expanding potentially dangerous dual-use capabilities across the globe. As the delayed response to H1N1 has demonstrated, the United States is woefully behind in its capability to rapidly produce vaccines and therapeutics, essential steps for adequately responding to a biological threat, whether natural or man-made.H1N1 came with months of warning. But even with time to prepare, the epidemic peaked before most
Americans had access to vaccine. A bioattack will come with no such warning. Response is a complex series of links in a chain of resilience necessary to protect the United States from biological attacks. Rapid detection and diagnosis capabilities are the first links, followed by providing actionable information to federal, state, and local leaders and the general public; having adequate supplies of appropriate medical countermeasures; quickly distributing those countermeasures; treating and isolating the sick in medical facilities; protecting the well through vaccines and prophylactic medications; and in certain cases, such as anthrax, environmental cleanup. We conclude that virtually all links are weak, and require the highest priority of attention from the Administration and Congress.
Whereas the Administration has demonstrated a keen understanding of the nuclear threat and has set in motion a series of policies that all hope will bear fruit, there has been no equal sense of urgency displayed towards the threat of a large-scale biological weapons attack.
The above quote came from page 2 of the Prevention of WMD Proliferation and Terrorism Report Card, produced by the Graham-Talent Commission on the Prevention of Weapons of Mass Destruction, Proliferation and Terrorism this month.
To the credit of the Commission, the report recognized the critical importance of having timely warning and an effective warning-response interface.
Enhance the nation’s capabilities for rapid response to prevent biological attacks from inflicting mass casualties [Grade: F] I fully agree with this assessment and would expand upon the example provided in the report of pandemic H1N1 to also include the following events:
From the perspective of the United States, biological threat events tend to be imported phenomenon. From an operational perspective, it matters little whether the event was triggered by natural, accidental, or intentional means when similar public health response measures may be required. Current ambiguity in social recognition of a "problem", lack of an effective National Weather Service-like alerting capability, time delays in engaging and reporting the results of credible laboratory and epidemiological investigations, and hesitation in the warning-response interface represents the deeper broken componentry of the "technical and operational capabilities... links in a chain" referred to by the Commission.
The social behavior of "patting ourselves on the back" with relief after both SARS and pandemic influenza remains troubling. It reveals a lack of sustained and prioritized social sensitization to the critical nature of this problem. My concern is a highly disruptive and mortal event on American soil such as the World Trade Center hit to "prove" the validity of the biothreat concern may be the only thing that mobilizes dedicated and prioritized effort. The classic Cassandra Effect so often seen in the human experience...
Strengthen domestic and global disease surveillance networks [Grade: C]. I completely disagree with this assessment. The grade here should also be "F". Current and ongoing problems include:
Propose a new action plan for achieving universal adherence to the Biological Weapons Convention [Grade B+]. I agree with this assessment and would refer readers to the National Strategy For Countering Biological Threats, which highlights the need for transparent reporting of disease events to support BWC compliance.
In closing, the assessment lacks recognition of the critical role of operational biosurveillance, a unique and newly emerging professional discipline whose objective is to provide timely warning of biothreats. Continued overemphasis in funding of technology and automated approaches to the exclusion of the human element in building an effective warning community will result in failure to realize an effective biodefense system for this country.
Nipah virus-related fatalities have once again been reported in Bangladesh, a country that has consistently reported outbreaks since 2001.
Nipah encephalitis is associated with a history of "panic" reporting with evidence of protective behaviors and public-initiated evacuation of affected communities in Bangladesh. Nipah outbreaks in Bangladesh are historically associated with very high disruption potential for involved communities in Bangladesh, up to and including temporary community disintegration. It is one of the few infectious diseases capable of generating true disaster conditions if containment is not achieved quickly.
The situation is assessed to be a crisis for the time being.