We have previously highlighted exposure of the international community to MERS-CoV case translocation by airflight, based on KSA being a point of origin for the virus. It is notable that the UK, Germany, and France were all highlighted at that time (December 2012) as possible translocation recipients. WHO would later confirm this anticipatory observation.
Here we remind the readers that the translocation potential for MERS-CoV has expanded. Below is a list of the countries who receiveair traffic from KSA, Jordan, Qatar, and UAE, based on 2006-2011 air traffic statistics:
|Destination Country||Total Passengers 2006-2011|
|UNITED ARAB EMIRATES||994309|
|HONG KONG SAR||743533|
|IRAN (ISLAMIC REPUBLIC OF)||354861|
|REPUBLIC OF KOREA||227954|
|SYRIAN ARAB REPUBLIC||132428|
|LIBYAN ARAB JAMAHIRIYA||78665|
|UNITED REPUBLIC OF TANZANIA||65885|
There are several key observations that should be apparent to the reader:
With the 2013 Hajj (in mid October) approaching, preparedness plans for emergency department and intensive care unit staff in these countries should be carefully reviewed.
In regards to claims by the WHO and other pundits of MERS-CoV representing a "global threat" or being representative of a "pandemic", we do not agree with these assessments. Recipient countries have been able to manage translocated cases well within the limits of their capabilities thus far.
We have seen a great many well-respected experts over the years claim that pathogens such as Ebola, SARS, H5N1, or HIV/AIDS might form a "super pandemic" and end life as we know it. Yet, Ebola, SARS, and H5N1 have not become a pandemic. Acknowledged, it is possible H5N1 may someday gain enough mutations, but that had not occurred yet. And it might not occur for another 50 years. HIV/AIDS did become a pandemic, however it has not brought the end of humanity as so many feared in the beginning.
We've seen Richard Danzig claim the end of America with aerosolized anthrax, only to be revealed as padding his nest via conflict of interest. I was present at a National Defense University conference on weapons of mass destruction as one of the few operators in the room who "stood the watch". Danzig presented an eloquent speech on aerosolized anthrax bringing down the entirety of our nation. At the time, I felt a sense of irritation. Irritation because I lived in the daily milieu of global reporting and well-understood the operational reality: that such talk often distracts us from other disruptive biological threats that stand right before us. I walked up to the mike during the Q&A and pointed out the obvious by saying, "Mr. Danzig, while we do not disagree with the threat, in general, of biological terrorism, Mother Nature can be a jealous mistress. How do your concerns help our country should the next pandemic arrive?" He was clearly annoyed with the question and looked down at his podium in disgust.
A couple of years later, it was not aerosolized anthrax but pandemic H1N1 that threatened President Obama's visit to Mexico (and the rest of the world). But, all the world had been focused for years on SE Asia, fearful of H5N1. This included myself, who had even written a peer-reviewed assessment of the need to maintain focus on SE Asia as the origin of the 1889 (?), 1918 (?), 1957, and 1968 pandemics along with SARS. Thank heavens we took the operational stance of needing to watch the entire world, ready for the unexpected. It is left to the imagination if Danzig et al believed a pandemic was a national security issue- especially after the point made during the NDU conference was made manifest.
Then we have the crowd of Tara O'Toole, DA Henderson, Tom Inglesby, et al from the UPMC Biosecurity Center. Through various table tops and exercises they too prophysized the coming plague of... plague, anthrax, and other intentional release events. Typically, there was a leap in these prophysied scenarios to chaos and mahem that would severely damage our country. Yet when queried, none of these individuals had heard of what happened in Rhodesia or had taken a close look at what happened in Manchuria during the Japanese deployments. Apparently, it is an inconvenient truth to suggest that communities are a bit more resilient than we give them credit for.
And now we have round after round of television pundits such as Laurie Garrett espousing MERS-CoV as the "next pandemic". It appears her unfulfilled assertions that SARS, H5N1, and H7N9 becoming the next pandemic has not in the least tempered the continued pattern of declaring "apocalypse now" with the discovery of any new pathogen capable of killing a human.
But let's give Ms. Garrett a break. She is ramping off WHO/Margaret Chan's comments that MERS-CoV is a "global threat". Yes, the world needs to pay attention to this pathogen and develop countermeasures. Yes, we expect further cases to shed sporadically into the air traffic grid. Yes, it is possible the pathogen may, unrecognized, enter a megalopolitan area via the air traffic grid and cause another Toronto. However, it is less likely than SARS because it is now a known threat associated with a substantial flow of pre-emptive warning information. No, this pathogen is not capable of generating a pandemic or true global threat. Very few infectious agents are associated the kind of epidemiological features to ensure this. And even those agents capable of generating pandemics do not induce a bi0logical bottleneck event.
Nevermind the virologists and molecular geneticists crying "apocalypse" with the notation of every concerning new gene in an influenza virus such as H7N9. Despite being reminded that there exists no capability that can reliably forecast a "pandemic" from a genomic sequence... despite being reminded that predicting systemic effects from microscopic observations is dubious at best.
Summary points to consider:
The world deserves a measured and well-balanced communication of risk provided by experienced professionals. Some of the recent blowback on the Danzig fiasco and the Garrett article should be a message to those who engage in the hyperbole- that the public is on to this behavior, and it is not acceptable. A higher standard is being called for here, and we need competent leadership to take this to heart.
Here we present the footprint of demand for pediatric medical countermeasures, this time with a focus on antimicrobials and other medications often associated with the treatment of infectious disease. This is an indirect and even oblique way of assessing whether antimicrobials are being used properly, especially when compared to the infectious disease signature libraries we have across infant, pediatric, and adult case loads. Forecasting drug use provides an interesting point of validation for forecasted infectious disease for which many of these drugs are used.
Upper Respiratory Infections and Eyes, Ears, Nose, and Throat
A/B Otic. Used as an analgesic for ear infections.
Amoxicillin. Used most commonly for ear infections, however also used for urinary tract infections.
For several years, we have operationally validated the forecasting of infectious disease in a manner analogous to meterology. We also demonstrated to the world that prioritization of warning for unusual infectious disease crises through the recognition of non-epidemiological indicator patterns may prompt rapid verification and earlier response.
Our examples have included warning of the H1N1 pandemic and cholera in Haiti. In the case of Haiti, the process directly contributed to recognition of the United Nations as the source of the cholera disaster. We also demonstrated robustly that the earlier one recognized villages experiencing first contact with cholera (in the context of immunological naivety), the earlier one was able to prompt swarm medical response and reign in horrendous case fatality rates. This was particularly true for rural villages far off-grid in the mountainous areas of the country.
We have previously shown the world, for the first time, the ability to forecast an entire event signature library for Ebola virus activity in Uganda. Below is another example, this time for H5N1 activity in Indonesia. It is important to note that we have the ability now to distinguish patterns between pathogens, and that similar to sequences in a genome there are sequences to human behavior that facilitate rapid recognition of the unusual. ... Particularly when the end-to-end process is fully automated.
Anticipation is the key to rapid recognition.
Directly from the Alabama Department of Public Health (ADPH):
On 5/16/13, a pulmonologist in Southeast Alabama reported to the Alabama Department of Public Health (ADPH) that three patients had been hospitalized with cough, shortness of breath, and pneumonia, were on ventilators, and had no known cause for their illness. The ADPH and the Houston County Health Department began an epidemiology investigation to interview the families about travel and exposure. Specimens were requested and submitted to the ADPH Bureau of Clinical Laboratories (BCL) in Montgomery.
On 5/17/13, BCL reported one of the three patients tested positive for 2009 H1N1. On 5/18/13, this patient died. On 5/19/13, the same hospital reported that a transferred patient on a ventilator with respiratory symptoms had died. On 5/19/13, this hospital had nine additional patients present to the emergency department with influenza-like illness and three of those patients were admitted. Specimens have been collected on all patients.
The BCL has tested all specimens on a PCR flu panel and one tested positive for AH3. The specimens were also forwarded to CDC for additional testing. At this time, there is no epidemiological link between these patients. While two patients have tested positive for influenza, the exact role of influenza in this cluster is unknown.
On 5/21/13, ADPH sent a News Release regarding the situation. ADPH has reiterated that healthcare providers should use standard precautions when dealing with patients with respiratory illness. Physicians should use clinical judgment in determining the best treatment for their patients since the etiology of the outbreak is unknown at this time.
Additional points of clarification:
We note the failure to follow up with the prior press release, as this information was not publicly released to our knowledge. We also note failure by CDC to provide an integrative comment regarding the situation in Houston, Texas. This, in our opinion, is an example of ineffective risk communication by public health authorities.
Over the last several weeks we have been engaged in debate with molecular geneticists over H7N9 and whether the pathogen could represent "the next Big One"... i.e. the next influenza pandemic.
We pointed out that thanks to ever-advancing diagnostic technology, we as a society are increasingly at risk of scaring ourselves because we are actually able to "see" threats and give them a name more quickly. This is a common phenomenon in novel warning systems, where a period of adjustment is needed before the operator no longer jumps at each and every blip on the radar.
We pointed out that highly successful and respected experts in genetics and select agent research have often made grand claims of threat associated with such pathogens as Ebola and SARS and H5N1. Words such as "Super Pandemic" were quoted in the media in the late 1990s, for instance, when discussing Ebola. However we have not seen the hyperbole become real.
We pointed out there remains a challenge to the operational biosurveillance triage, where one asks the uncomfortable question of how you "rack and stack", or prioritize, infectious agents to monitor. Whether these geneticists believed H7N9 or H5N1 should take priority? Or H3N2 variant (which is inside the United States)? Or perhaps canine influenza (H3N8)? We were met with silence.
We provided a concluding point that there remains lack of confidence (and proof) that we are able to predict, based on genetic sequences, which influenza virus will become the harbinder of the next pandemic. This, of course, caused discomfort in the discourse.
And now H7N9 has reportedly cooled off, and the world has refocused on novel coronavirus as it continues to slowly leak into the international air traffic grid. About a month ago, we pointed out here on Operational Biosurveillance the signature patterns for novel coronavirus remained more concerning than H7N9. We are aware of one pharmaceutical company who used that information to prioritize their resources towards analysis of the novel coronavirus genome and production of a vaccine.
Herein lies a point: that should we achieve a degree of fidelity in operational forecasting, warning, and tactical assessments, then the organization capable of acting on that information is strategically positioned ahead of a potential crisis. And strategically positioned ahead of the market. This could mean rapid development of a diagnostic kit, vaccine, or other countermeasure.
Herein lies another point: that the global markets require a balanced perspective when attempting to understand these uncertain, emerging infectious disease crises. That the yammer of pundits is not always correct in their asserted assessments of these situations. That discovery of a novel pathogen (thanks to novel technology) does not equate to The Next Big One. And that the world only knows what is recognized by the major media outlets- that a virtual iceberg of daily information regarding deadly infectious disease resides buried in other languages and online sources.
And lastly, that a deep breath is needed with that grain of salt when reading the continuous flow of hyperbole.
Our team is in the midst of communication with Dothan-local critical care specialists who have indicated local EMS and emergency department staff are wearing N95 masks. The area intensive care units are on alert. There is apparently a local concern for potential extension of the outbreak to Pensacola. So far, there is no information to link what was reported in Houston, TX and what is now being reported in Dothan, Alabama. Further, there appears to be little information regarding etiology of this fatal respiratory disease.
Questions we have is whether diagnostic testing has been done for A/H3N2 variant or other variant influenza viruses, adenovirus, or if this is a cluster of Staph-influenza coinfections. We do not believe it likely we are dealing with H7N9 or novel coronavirus. It is disconcerting CDC is not providing information to the public.