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What does the United States need to do to keep the nation safe as these diseases threaten the well-being of the world's population?

Discussion Leader: 
Dr. Andy Kilianski
Posted Date: 8/31/2015

This week's thought-provoking question is based on two HDIAC Spotlights looking at emerging diseases around the world. MERS, Malaria and other diseases affect hundreds of thousands of people across the globe and have impacted our military conducting operations in affected areas. 

Scanning electron micrograph of Plasmodium gallinaceum invading mosquito midgut. (Photo courtesy of the National Institute of Allergy and Infectious Diseases)

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Comments

Welcome to the HDIAC question of the week! I'll be moderating the topic this week, and hopefully we have some thoughtful discussion on the impact of emerging diseases on deployed force health protection.

A little bit of background to start. I'm a microbiologist for the US Army at Edgewood Chemical Biological Center. We do a lot of work in this topic area, and its something that is of concern to the Army but also to greater public health.

Going forward, where should the US focus its resources to combat this issue? As populations impinge on habitats harboring endemic zoonotic diseases, how will we better protect our deployed forces and the local populations? Answering these questions will be critical for combating emerging diseases both here at home and abroad. I look forward to your thoughts!

As I read more and more about emerging diseases around the world (MERS/Malaria/Ebola/etc.) it seems that vaccination and prevention need to be a primary focus. It appears incredibly difficult to stop an outbreak once it gets going. In addition to prevention, detection of emerging diseases before they turn into outbreaks is important. 

But, I don't think the United States can do it alone. I think there needs to be global cooperation to ensure diseases are recognized before it's too late and vaccinations are developed and implemented ahead of an outbreak.

If the United States is going to take no risks for her personnel, then the focus should be on prevention. As JHill stated, trying to corral the problem after an outbreak occurs is far more difficult than preventing one. With adequate protection, the military and state personnel are less likely to bring back infectious diseases than civilians.

One major flaw in addressing emerging diseases for civilians is the reliance on single methods to combat them. For example, many travelers opt for the antimalarial pills as a way to prevent coming down with Malaria in South East Asia. The pills are quite effective, but not 100%. That being said, I knew of only a handful who combined these antimalarials with other methods of protection such as a bed net or insect repellent, as they felt that the pills were all that was necessary to prevent infection. On the flip side, Antimalarials are quite cheap when compared to Japanese Encephalitis prevention. While the price fluctuates, I believe the shot was around $300+ back in 2013-2014. Oddly enough, most travelers in the jungles and wetlands opted out of the shot, instead using insect repellent and bed nets or long clothing as prevention methods. These methods were far more crude and risky, but came at a much lower cost to the civilian and put them at higher risk of catching the disease. While JE is not transmittable from human to human, the risk behavior shown by civilians make it clear that commutable diseases could also easily be brought back to the US.

The safest bet in both instances would be combined methods, as neither one on their own offers 100% protection. By overlapping protection methods you reduce the risk of infection and the downtime associated with having to cure.

Emerging diseases (like Ebola, MERS, Malaria, Chikungunya, etc.) are a major threat to public health. Vaccinations and detection are two key areas of combating diseases before they turn into global outbreaks. I would like to add that I think the main question is how can we improve detection of these diseases? The earlier the detection, the faster we can prepare to decrease the disease dissemination, including increasing vaccination supply, awareness to the public, and close monitoring of travel. Many studies have been conducted that focused on detection of emerging infections and, although some of the methods are unorthodox, we need to use every tool available to identify emerging diseases before they spread.

 

One method for predicting emerging diseases is tracking searches of search engines (e.g. Google), traffic data of webpages about disease (e.g. Wikipedia), and mentions on social media (e.g. Twitter).  Monitoring and analyzing these online trends may give clues as to what outbreaks are possible because these online areas are publicly available for free and they can reflect growing interest of the population regarding diseases.  Although this method is not fool-proof, for example areas with low internet connectivity are a major factor, it can be combined with the common methods public officials use to track illnesses and gets us one step closer to early detection.

 

Another interesting method of detection uses feces from airline restrooms to track various microbes. A recently published study in Scientific Reports mentions sequencing genomes of microbes in feces to discover trends of global health. This study has fueled MIT to do a similar study using sewage water in Cambridge to analyze biomarkers and reveal information regarding local public health.

 

Another method of detection, discussed in the HDIAC Spotlight "Predicting Infectious Disease Outbreaks," involves the use of drones to strategically place mosquito traps and use them to collect data to act as pathogen surveillance systems. Although this has been done manually in the past, this new method would allow for the process to happen faster and have the ability to sort mosquitoes from other pests.

 

I think one of the greatest contributions the United States and its global allies can make to disease prevention is to continue researching and developing new methods for identifying emerging diseases. The new methods for tracking and detecting emerging diseases, along with traditional outlets for tracking outbreaks (e.g. monitoring doctor’s reports), can provide quicker detection and response time to potential infectious outbreaks.  

Thank you all for your very interesting comments. Your thoughts all drive at one of the very core problems with this issue, lack of knowledge. How do you combat what you don't know about? And how do you prioritize funding to attack unknown problems related to emerging disease vs. antibiotic resistance, HIV/AIDS, or influenza (which cause more morbidity/mortality and cost much more money than emerging diseases). I'll use two examples here mentioned above:

MERS-CoV: This virus was completely unknown prior to its discovery in humans. Since SARS-CoV (which was also unknown), researchers had found other coronaviruses present in humans and animals, but none similar to MERS-CoV and none capable of the disease manifestations in humans caused by MERS-CoV. Vaccines and antivirals can't be developed because nobody knew about MERS-CoV, and there aren't specific detection assays developed because again, it was an unknown.

The emergence of unbiased characterization methods (whole-genome sequencing, mass spectrometry) will allow for us to survey animal/environmental populations to find novel potential human diseases. This is good, because we can identify these agents prior to introduction into humans. It also causes a problem, because there are thousands and thousands of agents that do NOT cause human disease. It will be hard to determine what the agents of interest should be.

Countermeasure and vaccine developers are moving towards broad-spectrum antiviral development and the creation of vaccine platforms that can be quickly engineered to vaccinate against an agent of interest. However, these are still a long way away. These challenges illustrate how difficult it is to prepare for what you don't know about before an outbreak occurs.

Ebola virus: The reason why there was no Ebola virus vaccine or countermeasure ready was for two linked reasons; lack of perceived threat and lack of money. The reality is that it takes a lot of money and a lot of risk to develop one of these products into a clinically approved drug or vaccine. In a sense, we got lucky with Ebola virus because there were a variety of products in various stages of clinical trials, allowing for their rapid deployment through cooperation with the FDA. If the Ebola virus outbreak didn't happen, we would not be seeing these products in clinical trials today, and they might have stalled where they were due to lack of interest from governmental parties (like BARDA/HHS and DoD) and thus lack of money and support for their development.

Prioritizing existing funding streams and creating new opportunities to explore these "neglected" infectious diseases will be very important moving forward. As you all illustrated above, there are significant gaps ranging from biosurveillance, detection, vaccine and countermeasure deployment, and outbreak response that need to be addressed to ensure both US and international public health.

One subject that has not been mentioned yet is education. The rapid spread of some of these disease (Ebola in particular) was due to a lack of knowledge about disease prevention in the population. It's difficult to contain a disease when people don't realize how it's spread or how to properly disinfect. I would think some form of education about disease transmission in less developed countries would be a necessary part of health prevention plans. 

I think an issue stemming from the attempt to educate individuals is the culture within the affected countries. In the instance of the Ebola outbreak, the countries affected have traditional practices that involve relatives to have extensive contact with the individual before he or she dies, as a way to prepare the body for burial. It is not unusual that people in Africa want to also rinse or wash the body before it is buried, causing individuals to come in contact with bodily fluids. There is a continuous struggle with public health workers educating these people on infection control, becuase it directly interferes with religion and other cultural beliefs. For future outbreaks in areas that have similar cultures/beliefs, expressing the fact that they will not be able to care for loved ones once infected will be difficult.