Outbreaks of Ebola, Zika highlight preparation shortfalls

Ebola was discovered in 1976 amid two outbreaks in Africa, including one in the Democratic Republic of the Congo near the river from which the virus draws its name. Decades later, beginning in March 2014, Ebola caused an outbreak in West Africa that killed more than 11,000 people — an example, according to one recent report in the New England Journal of Medicine, that the world is “ill-prepared” for such an infectious disease crisis.

On Feb. 1, about 2 weeks after announcing the end of the Ebola outbreak in West Africa, WHO declared that the threat posed by Zika — a virus first isolated from monkeys in Uganda’s Zika forest in 1947 — constituted a Public Health Emergency of International Concern. Since then, as Zika has swept across the Americas, infecting tens of thousands of people, the CDC has declared there is no longer any doubt the virus can cause microcephaly and other severe birth defects, and researchers have learned that the primarily mosquito-borne virus also can be sexually transmitted. Meanwhile, the United States government has deliberated over how much money to earmark for the Zika response, and fears about the virus have led to a debate about whether the Summer Olympics should be held in August as planned in Brazil, the epicenter of the outbreak.

These are examples of how the world, even with decades of warning, may seem more inclined to react to outbreaks of infectious disease rather than prepare for them.

“Most of the time it seems like we’re just dealing with the outbreak itself, so we don’t get to the point where we can actually spend time doing more to prepare ourselves,” Angelle Desiree LaBeaud, MD, MS, associate professor of pediatrics and infectious disease at Stanford School of Medicine’s Lucile Salter Packard Children’s Hospital, told Infectious Disease News.

Angelle Desiree LaBeaud

Fighting diseases ‘over there’

In a shrinking and better-connected world, outbreak preparation can start overseas.

“The world is different than it was in 1976,” Liise-anne Pirofski, MD, chief of infectious diseases at Albert Einstein College of Medicine and Montefiore Medical Center in New York, said in an interview.

Liise-anne Pirofski

Indeed, the decades since Ebola was first discovered have revealed how connected and small the world has become, and how public health problems in other countries are not necessarily theirs alone, LaBeaud said.

“The days are over when countries can think, ‘Oh, we don’t have that infection here. It’s on the other side of the world. We’re not at risk,’ ” she said. “Things move around quite quickly and quite easily.”

One way to stop outbreaks from spreading internationally is to deal with the diseases where they are occurring, LaBeaud said.

“When you do that, you’re helping the local community and decreasing the risk that the infection will spread, because transmission occurs when people travel and bring the infection with them,” she said.

The recent Ebola outbreak centered around three countries — Guinea, Liberia and Sierra Leone — but cases also were confirmed in Mali, Nigeria, Senegal, Italy, Spain, the United Kingdom and the United States, where one person died.

“If you look at a map of Africa, it’s staggering to see how small those three countries are,” Pirofski said. “They’re just on that tiny little tip in West Africa, and yet Ebola’s impact was global.”

According to Pirofski, the lack of preparedness for an Ebola outbreak was evident in the slow realization of how big the epidemic had become, and in how many first responders and health care workers died.

“They were inadequately prepared. They didn’t have the things they needed. They didn’t have the personal protective equipment, and getting it there was slow,” she said. “Local public health authorities didn’t really have what they needed to take care of large numbers of people.”

Spending on prevention is cost-effective

To address the shortcomings made evident by Ebola, the U.S. National Academy of Medicine convened an independent commission of international experts to set a framework for better outbreak responses in the future. The commission, which issued its report in January, urged the G7, G20 and United Nations to allocate $4.5 billion a year for disease prevention. In contrast, the commission said, potential pandemics could amount to a worldwide economic loss of around $60 billion annually.

“The commission’s report makes the case for greater investment in countering infectious disease threats, arguing that potential pandemics should be considered not just as important health risks, but as major threats to the global economy and security,” Peter Sands, MPA, chair of the commission, and colleagues wrote in the New England Journal of Medicine.

LaBeaud agrees that directing more money to battle infectious diseases — even those that seem distant — is one way to be better prepared for outbreaks. She posed a hypothetical example of spending U.S. tax dollars on an outbreak of Zika virus in French Polynesia that began in 2013. According to a study published in Science, that outbreak coincided with the introduction of Zika into the Americas by a single traveler sometime between May and December 2013 — more than a year before it was first detected in Brazil. Using genomic data, the researchers found that the virus at the center of the current Zika outbreak was most closely related to a strain from French Polynesia.

“[People might think], ‘Does this have anything to do with us? How is this going to impact us?’ That thinking has got to end, because here we are,” LaBeaud said. “The funders have to remember that it’s a small world, and I think they’re starting to do that. But more can be done.”

It is cost-effective to spend resources on better surveillance and investigation, Pirofski said.

“That has to be cheaper than dealing with very large numbers of [sick] people,” she said. “Ebola was a complete humanitarian catastrophe. Those three countries basically came to a halt. They lost young people, their teachers, their hospitals, their health care workers and a substantial portion of their economy.”

It is also important to make preparations in case outbreaks spread. In New York, where there is a large West African population, many hospitals, including Montefiore where Pirofski directs the infectious diseases division, built dedicated Ebola units with the knowledge they might never see a patient.

“I frequently tell people these days that in our field, ‘When the world changes, we have to change,’ ” she said. “We may never see a case, but we had to be prepared because we are a part of this world. We had returning travelers that we needed to triage.”

The media’s responsibility

LaBeaud said the media can play a role by covering outbreaks no matter where they happen. She first heard about Zika during the 2007 outbreak on the Pacific island of Yap, where an estimated 73% of the population aged 3 years and older was infected with the virus, according to another report in the New England Journal of Medicine.

Yet, LaBeaud said, the money needed to study Zika was not available because the virus was perceived as being too far away to be important or dangerous. The attention increased once Zika was linked to microcephaly, she said.

“We might have had some basic fundamental questions answered if there had been more open-mindedness when it came to the funders and if the media had actually covered that story,” LaBeaud said.

One issue that did draw attention recently was the detection of the antibiotic-resistant mcr-1 gene in a patient in the United States for the first time. The discovery led to a congressional hearing about the federal response to superbugs and the threat of antibiotic resistance.

During testimony, Beth P. Bell, MD, MPH, director of the National Center for Emerging and Zoonotic Infectious Diseases at the CDC, called antibiotic resistance “perhaps the single most important infectious disease threat of our time.” She said the increased surveillance that detected the mcr-1 gene in a Pennsylvania patient being treated for a urinary tract infection (it was discovered by Defense Department researchers) showed that such measures can have an impact on outbreak prevention and response.

“We know that, although much effort is being expended to develop new antibiotics, we also must work right now to slow the spread of these resistant bacteria and improve how we use the antibiotics we have,” Bell said.

‘We have to be much more nimble’

According to LaBeaud, taking steps to prepare for outbreaks is more difficult in countries where issues related to politics and war interfere and where funding falls short. Also, some outbreaks are unforeseeable.

“The U.S. tries to stay on top of these things, but not all of this is completely predictable,” she said. “Either the scale is unpredictable, or the location is unpredictable.”

Pirofski agrees that not everything is predictable — “wild cards” such as climate change, the introduction of organisms into new areas and social and political factors contribute to virulence.

“The predictability is not always going to be there, but we can probably do better,” she said. “I think that we’re going to have to deal with the fact that we have to be much more nimble. We have to be much more on our guard when we see something unusual. And what that requires is redoubling our efforts to make sure we pay attention to unusual clusters of illness or phenomena that are not easily explained by current information. The clinical observation that there seemed to be more cases of microcephaly in areas where Zika infections were occurring led to a proposed association between Zika infection and microcephaly, which in turn led to experimental proof that Zika infection can cause microcephaly.”

No ‘magic equation’

There is no one-size-fits-all approach to battling disease outbreaks, LaBeaud said. For example, some infections are highly emergent but may not cause much disease, while others are less likely to emerge but more dangerous when they do.

LaBeaud mentioned Rift Valley fever virus (RVFV) — a zoonotic virus first identified in 1931 in Kenya. RVFV can cause severe disease in domesticated animals such as cattle, sheep, camels and goats, as well as humans, according to WHO. Humans are most often infected through contact with the blood or organs of infected animals, although mosquitoes also can transmit the virus.

Most Americans have probably never heard of RVFV, according to LaBeaud, even though the virus presents a risk to them.

“It can be transmitted by so many different animal species and by so many different vectors that once it’s introduced, it’s very hard to eradicate and get out of the ecosystem,” she said. “It would annihilate our $3 billion livestock industry. There would be huge economic and probably human health consequences if Rift were to come here.”

The virus has only been documented outside of Africa once, in September 2000, when cases were confirmed in Saudi Arabia and Yemen, raising concerns that it could spread to other areas of Asia and Europe, according to WHO.

“It’s another infection that has shown us it can move,” LaBeaud said. “There are probably many more. We don’t have a magic equation yet where we can put in all these different factors to identify the most emergent and important infections. We just have to observe what’s happening in the world and pay attention. If an infection is causing an explosive epidemic in some remote region of the world and 75% of that population is getting impacted, it’s probably an infection that we should observe, monitor, research and worry about a little bit.

“Knowing what’s actually circulating in the world and where, and what kind of problems it’s causing, could probably do a lot to protect us and make us more prepared for these things.” – by Gerard Gallagher

Disclosures: Bell, LaBeaud, Pirofski and Sands report no relevant financial disclosures.

Ebola was discovered in 1976 amid two outbreaks in Africa, including one in the Democratic Republic of the Congo near the river from which the virus draws its name. Decades later, beginning in March 2014, Ebola caused an outbreak in West Africa that killed more than 11,000 people — an example, according to one recent report in the New England Journal of Medicine, that the world is “ill-prepared” for such an infectious disease crisis.

On Feb. 1, about 2 weeks after announcing the end of the Ebola outbreak in West Africa, WHO declared that the threat posed by Zika — a virus first isolated from monkeys in Uganda’s Zika forest in 1947 — constituted a Public Health Emergency of International Concern. Since then, as Zika has swept across the Americas, infecting tens of thousands of people, the CDC has declared there is no longer any doubt the virus can cause microcephaly and other severe birth defects, and researchers have learned that the primarily mosquito-borne virus also can be sexually transmitted. Meanwhile, the United States government has deliberated over how much money to earmark for the Zika response, and fears about the virus have led to a debate about whether the Summer Olympics should be held in August as planned in Brazil, the epicenter of the outbreak.

These are examples of how the world, even with decades of warning, may seem more inclined to react to outbreaks of infectious disease rather than prepare for them.

“Most of the time it seems like we’re just dealing with the outbreak itself, so we don’t get to the point where we can actually spend time doing more to prepare ourselves,” Angelle Desiree LaBeaud, MD, MS, associate professor of pediatrics and infectious disease at Stanford School of Medicine’s Lucile Salter Packard Children’s Hospital, told Infectious Disease News.

Angelle Desiree LaBeaud

Fighting diseases ‘over there’

In a shrinking and better-connected world, outbreak preparation can start overseas.

“The world is different than it was in 1976,” Liise-anne Pirofski, MD, chief of infectious diseases at Albert Einstein College of Medicine and Montefiore Medical Center in New York, said in an interview.

Liise-anne Pirofski

Indeed, the decades since Ebola was first discovered have revealed how connected and small the world has become, and how public health problems in other countries are not necessarily theirs alone, LaBeaud said.

“The days are over when countries can think, ‘Oh, we don’t have that infection here. It’s on the other side of the world. We’re not at risk,’ ” she said. “Things move around quite quickly and quite easily.”

One way to stop outbreaks from spreading internationally is to deal with the diseases where they are occurring, LaBeaud said.

“When you do that, you’re helping the local community and decreasing the risk that the infection will spread, because transmission occurs when people travel and bring the infection with them,” she said.

The recent Ebola outbreak centered around three countries — Guinea, Liberia and Sierra Leone — but cases also were confirmed in Mali, Nigeria, Senegal, Italy, Spain, the United Kingdom and the United States, where one person died.

“If you look at a map of Africa, it’s staggering to see how small those three countries are,” Pirofski said. “They’re just on that tiny little tip in West Africa, and yet Ebola’s impact was global.”

According to Pirofski, the lack of preparedness for an Ebola outbreak was evident in the slow realization of how big the epidemic had become, and in how many first responders and health care workers died.

“They were inadequately prepared. They didn’t have the things they needed. They didn’t have the personal protective equipment, and getting it there was slow,” she said. “Local public health authorities didn’t really have what they needed to take care of large numbers of people.”

PAGE BREAK

Spending on prevention is cost-effective

To address the shortcomings made evident by Ebola, the U.S. National Academy of Medicine convened an independent commission of international experts to set a framework for better outbreak responses in the future. The commission, which issued its report in January, urged the G7, G20 and United Nations to allocate $4.5 billion a year for disease prevention. In contrast, the commission said, potential pandemics could amount to a worldwide economic loss of around $60 billion annually.

“The commission’s report makes the case for greater investment in countering infectious disease threats, arguing that potential pandemics should be considered not just as important health risks, but as major threats to the global economy and security,” Peter Sands, MPA, chair of the commission, and colleagues wrote in the New England Journal of Medicine.

LaBeaud agrees that directing more money to battle infectious diseases — even those that seem distant — is one way to be better prepared for outbreaks. She posed a hypothetical example of spending U.S. tax dollars on an outbreak of Zika virus in French Polynesia that began in 2013. According to a study published in Science, that outbreak coincided with the introduction of Zika into the Americas by a single traveler sometime between May and December 2013 — more than a year before it was first detected in Brazil. Using genomic data, the researchers found that the virus at the center of the current Zika outbreak was most closely related to a strain from French Polynesia.

“[People might think], ‘Does this have anything to do with us? How is this going to impact us?’ That thinking has got to end, because here we are,” LaBeaud said. “The funders have to remember that it’s a small world, and I think they’re starting to do that. But more can be done.”

It is cost-effective to spend resources on better surveillance and investigation, Pirofski said.

“That has to be cheaper than dealing with very large numbers of [sick] people,” she said. “Ebola was a complete humanitarian catastrophe. Those three countries basically came to a halt. They lost young people, their teachers, their hospitals, their health care workers and a substantial portion of their economy.”

It is also important to make preparations in case outbreaks spread. In New York, where there is a large West African population, many hospitals, including Montefiore where Pirofski directs the infectious diseases division, built dedicated Ebola units with the knowledge they might never see a patient.

“I frequently tell people these days that in our field, ‘When the world changes, we have to change,’ ” she said. “We may never see a case, but we had to be prepared because we are a part of this world. We had returning travelers that we needed to triage.”

The media’s responsibility

LaBeaud said the media can play a role by covering outbreaks no matter where they happen. She first heard about Zika during the 2007 outbreak on the Pacific island of Yap, where an estimated 73% of the population aged 3 years and older was infected with the virus, according to another report in the New England Journal of Medicine.

Yet, LaBeaud said, the money needed to study Zika was not available because the virus was perceived as being too far away to be important or dangerous. The attention increased once Zika was linked to microcephaly, she said.

“We might have had some basic fundamental questions answered if there had been more open-mindedness when it came to the funders and if the media had actually covered that story,” LaBeaud said.

One issue that did draw attention recently was the detection of the antibiotic-resistant mcr-1 gene in a patient in the United States for the first time. The discovery led to a congressional hearing about the federal response to superbugs and the threat of antibiotic resistance.

PAGE BREAK

During testimony, Beth P. Bell, MD, MPH, director of the National Center for Emerging and Zoonotic Infectious Diseases at the CDC, called antibiotic resistance “perhaps the single most important infectious disease threat of our time.” She said the increased surveillance that detected the mcr-1 gene in a Pennsylvania patient being treated for a urinary tract infection (it was discovered by Defense Department researchers) showed that such measures can have an impact on outbreak prevention and response.

“We know that, although much effort is being expended to develop new antibiotics, we also must work right now to slow the spread of these resistant bacteria and improve how we use the antibiotics we have,” Bell said.

‘We have to be much more nimble’

According to LaBeaud, taking steps to prepare for outbreaks is more difficult in countries where issues related to politics and war interfere and where funding falls short. Also, some outbreaks are unforeseeable.

“The U.S. tries to stay on top of these things, but not all of this is completely predictable,” she said. “Either the scale is unpredictable, or the location is unpredictable.”

Pirofski agrees that not everything is predictable — “wild cards” such as climate change, the introduction of organisms into new areas and social and political factors contribute to virulence.

“The predictability is not always going to be there, but we can probably do better,” she said. “I think that we’re going to have to deal with the fact that we have to be much more nimble. We have to be much more on our guard when we see something unusual. And what that requires is redoubling our efforts to make sure we pay attention to unusual clusters of illness or phenomena that are not easily explained by current information. The clinical observation that there seemed to be more cases of microcephaly in areas where Zika infections were occurring led to a proposed association between Zika infection and microcephaly, which in turn led to experimental proof that Zika infection can cause microcephaly.”

No ‘magic equation’

There is no one-size-fits-all approach to battling disease outbreaks, LaBeaud said. For example, some infections are highly emergent but may not cause much disease, while others are less likely to emerge but more dangerous when they do.

LaBeaud mentioned Rift Valley fever virus (RVFV) — a zoonotic virus first identified in 1931 in Kenya. RVFV can cause severe disease in domesticated animals such as cattle, sheep, camels and goats, as well as humans, according to WHO. Humans are most often infected through contact with the blood or organs of infected animals, although mosquitoes also can transmit the virus.

Most Americans have probably never heard of RVFV, according to LaBeaud, even though the virus presents a risk to them.

“It can be transmitted by so many different animal species and by so many different vectors that once it’s introduced, it’s very hard to eradicate and get out of the ecosystem,” she said. “It would annihilate our $3 billion livestock industry. There would be huge economic and probably human health consequences if Rift were to come here.”

The virus has only been documented outside of Africa once, in September 2000, when cases were confirmed in Saudi Arabia and Yemen, raising concerns that it could spread to other areas of Asia and Europe, according to WHO.

“It’s another infection that has shown us it can move,” LaBeaud said. “There are probably many more. We don’t have a magic equation yet where we can put in all these different factors to identify the most emergent and important infections. We just have to observe what’s happening in the world and pay attention. If an infection is causing an explosive epidemic in some remote region of the world and 75% of that population is getting impacted, it’s probably an infection that we should observe, monitor, research and worry about a little bit.

“Knowing what’s actually circulating in the world and where, and what kind of problems it’s causing, could probably do a lot to protect us and make us more prepared for these things.” – by Gerard Gallagher

Disclosures: Bell, LaBeaud, Pirofski and Sands report no relevant financial disclosures.