Homeland Security Watch

News and analysis of critical issues in homeland security

November 1, 2014

Ebola source sitrep 3

Filed under: Biosecurity,Preparedness and Response,Public Health & Medical Care,Strategy — by Philip J. Palin on November 1, 2014

The World Health Organization released a new data summary late on October 29.  A few highlights:

The growth rate of transmission in West Africa seems to have slowed, especially in hardest hit Liberia.  This has surprised most close observers who suggest it is either the result of unrecognized and under reported transmissions or is a temporary trough in what can be a wave-like pattern on the part of the virus.

The region’s anti-Ebola capacity is much stronger now than at the beginning of October.  Several new diagnostic labs and treatment facilities are now in place (see map below).  Clinical personnel are more numerous and better equipped. Some have suggested the reduced transmission rate is the outcome of interventions — educational, clinical, and logistical — put in place over September and October.

Ebola Treatmentt

Despite this good news — or pause in worse news — a new scientific analysis published on Thursday concludes, “Under status quo intervention, our projections indicate that the Ebola outbreak will continue to spread, generating a predicted 224 (95% CI: 134 – 358) cases daily in Liberia alone by December…”  For the week ending October 25 fewer than 50 probable cases were reported in Liberia.

The key factor may be “status quo intervention”; how much effort, targeted where, will have the most effect?  It is widely recognized that the West African outbreak is the result of a failure to intervene early and effectively, before the virus was able to spread in dense urban environments.  The best evidence for this analysis being what has happened with an unrelated, but parallel, cluster of Ebola cases in the Democratic Republic of the Congo.

The first Ebola death in the DRC was on August 11.  The role of Ebola was identified before the end of August.  Aggressive public health measures were taken to isolate and treat those with the virus.  (Other factors probably helped.)  There have been a total of sixty-six cases and forty-nine deaths.  It has now been eighteen days since the last new case was identified.  The transmission cycle was contained and has apparently been stopped.

Public education and community involvement are, many emphasize, fundamental to this sort of success.  The same analysis projecting potential exponential growth in the number of West African Ebola victims found that four behavioral adjustments could produce a rapid decline in transmission (see chart below).  Of particular importance is a change in burial practices.  The “status quo” being studied was the situation in mid-September. Several of the practices have been increasingly adopted since.  Already enough to produce the recent declines?

Ebola 4 Interventions

Since the West African Ebola cases first emerged, many at HLSWatch have suggested that for the United States this is mostly an opportunity to “run the traps” for a much more easily transmitted, much less treatable infectious disease.  Important issues have surfaced related to early identification and treatment, clinical protocols, clinical training, and quarantine policy, strategy, and practice.

Some potentially less obvious lessons:

Isolation matters:  The economic isolation of eastern Guinea produced a level of poverty that resulted in hunting bats for food.  When a child and then his family members died of bat-borne Ebola they did not receive medical attention. The virus was given time to multiply.  In urban Monrovia the poverty-stricken West Point slum has been the epicenter of transmission.  The population’s lack of connectedness with wider society has impeded the application of effective public health strategies.

Culture matters:  Washing, caressing and otherwise honoring the body of dead family members has been a particularly virulent vector for transmission of the disease.  Working respectfully within the culture it has been possible — with remarkable speed — to adjust cultural behaviors.

Community matters:  Connecting those who were disconnected and building trust where there was little or none has been a precondition to adjusting population behaviors and bending the transmission curve.  Facilitating and supporting community self-organization has again and again been a big part of the public health approach.

Media matters:  Mass media and social media can significantly influence the velocity of public attitudes for both good and bad.   How to influence the velocity of media attention is, I suggest, quite similar to how we effectively engage the virus itself.  Think about it.

Reasoning matters:  Chris’ Tuesday post — and Haidt’s claim — have clearly been on my mind all week.  For what it’s worth, I perceive Haidt was mostly critiquing a tendency by some to perceive reason as self-evident and to dismiss those too stupid to recognize the obvious.  In this regard I agree with Bellavita and Haidt.  The noun can be pretentious.  But the verb — reasoning — when undertaken in a way that embraces culture, community, and respectful communication is the best tool we’ve got.

Maybe this is an opportunity to run the traps on more than the next infectious disease.

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Comment by William R. Cumming

November 1, 2014 @ 9:41 am

Thanks Phil! Excellent SITREP!

Comment by Arnold Bogis

November 1, 2014 @ 1:29 pm

Phil, I think in some measure the traps have been/are being run by this situation. Assuming you have been speaking with professionals who understand the extremely low risk of Ebola transmission inside the U.S., the current situation here might not seem like a big deal.

However, the media has shown itself highly resistant to education. Those with access to medical reporters and correspondents that should really know better often allow anchors to push the “what if” angle of the story. Or some outlets find any person with medical credentials to agree with the scariest story line.

I shudder to think what will happen during a truly dangerous infectious disease outbreak or even a dirty bomb explosion. There should be public health officials all around the country scratching their heads about why best standards of public messaging don’t seem to be working so well.

Also, despite many if not most commentators and media outlets ignoring this uncomfortable fact, it is the private sector that will be on the front lines of responding to health emergencies. Despite Obamacare, we do not have a socialized health care system. Unlike terrorism or other security threats, there is not a predominately federal/state/local government response. The CDC and other federal agencies have an important role to play, and it is state and local public health agencies that implement and attempt to enforce guidelines and if needed do the contact tracing required by infectious disease.

But it is and will be mainly private health care workers who are the white coats on the ground treating patients. Doctors, nurses, often medics and paramedics (though many of these individuals do work for government agencies) that have to implement the guidelines about which so many now criticize the federal government. With shrinking federal grant dollars, how will they be incentivized to carry out preparedness efforts? What is the business argument for losing money to spend time planning, training, and exercising?

It is always popular to point fingers at the federal government, no matter the party in power. Few dare criticize the beloved free market, but perhaps there are issues best not left to supply and demand? And how to convince hospital administrators to run the traps?

Comment by Philip J. Palin

November 1, 2014 @ 2:51 pm

Arnold, Thanks. You have health care expertise that I do not. But I wonder if it is less a private-public divide and more a matter of good or bad training/exercises?

The vast majority of public sector training/exercises I have observed — occasionally participated in — are awful. The training/exercising usually relates to tactical/procedural implementation of a bad plan. Training is superficial. Exercising consists mostly of checking-off-boxes. Very little real learning happens. Very little testing of actual capabilities happen. The plan is confirmed rather than tested.

I have participated in training/exercises that included public and clinical health providers/systems, but I have never participated in a primarily health care-oriented training/exercise. So I don’t know what I have not experienced.

I have experienced a few exciting, revealing, practically helpful training/exercising activities… more have been private sector, on a few occasions public. But most private training/exercising is pretty mind-numbing as well.

I also worry that all this bad training/exercising actually encourages the illusion/delusion that we are more prepared than is actually the case.

In terms of media… well, that deserves more time than I have today.

Comment by Christopher Tingus

November 1, 2014 @ 10:39 pm

Thanks and an interesting and informative post and Ebola which has fortunately adversely affected few in our population, however from a preparedness perspective, again shown the failure of this ever imposing government, so disorganized and so ill prepared!

In reading, Eugene Thacker Nomos, nosos and bios in the body politic:

The aims of such bioterrorist attacks seem to be geared more towards disruption than destruction. A news feature and heightened public anxiety are as important as the actual contagion of individuals.

Alongside this emerging consciousness of bioterrorism, the late twentieth and early twenty-first centuries have seen a drastic increase in the prevalence of ‘emerging infectious diseases’ (Garrett, 1994; Lashley, 2004; U.S. CDC, 2000).

While AIDS, tuberculosis, and malaria continue to impact many individuals and populations worldwide, there has also been the emergence of a range of diseases which are, arguably, of a different sort. Mad cow, West Nile, monkey pox, bird flu, and SARS have, at one time or another, made headlines. These diseases are highly unstable – in some they cause the flu, in others death – and they also display erratic patterns of contagion. But what is perhaps most noteworthy of such diseases is that they have been known to rapidly mutate, enabling them to cross species barriers (including the human-animal boundary), and they are often spread via modern means of transportation (airplanes, cargo ships). In the case of SARS in 2003, the condensed run of the disease (some six months) has become emblematic of the nature of these types of epidemics (Bell et al., 2003).

Poor sanitation conditions in rural poultry markets may have provided the conditions for the virus’s mutation, enabling it to jump from animals to humans. An extended incubation period in humans meant that infected individuals had time to travel by car, rail, and plane to other parts of China, southeast Asia, and Canada. Urban hotels and airports may have provided a further site for opportunistic infection as well.

In response to what was quickly becoming a global health issue, the World Health Organization (WHO) made use of computer networks to coordinate patient data, gather reports from selected hospitals, and issue air travel advisories to selected airports. That is, the WHO made use of information networks to counteract an epidemic network, information transmission to counteract biological contagion and technological transportation. The rapid spread of SARS from mainland China to Canada illustrated the tight relationship between contagion, transportation, and transmission.

Both bioterrorism and emerging infectious disease present us with unique instances in which the tension-filled zone between nomos and nosos is displayed in a new light. Specifically, the concurrence of bioterrorism and emerging infectious disease provides us with a biopolitical situation in which biology, information, and war all play a role. Consider the U.S. responses to these twin ‘threats.

On the issue of bioterrorism, the U.S. Public Health Security and Bioterrorism Preparedness and Response Act (2002) significantly increases the monitoring of a wide range of ‘suspect’ biological materials in the U.S. – including those used in legitimate, federally-funded, university-based biology labs (Kevles, 2003).2 Likewise, the U.S. Project BioShield, which was announced in 2003, offers unprecedented funds for three key areas: the development of ‘next-generation medical countermeasures’ (some $6 billion over the next ten years), NIH funding for those research projects that show promise in the development of vaccines and drugs to counter bioterrorist attacks, and new legislation which gives the U.S. Food and Drug Administration (FDA) the ability to designate ‘fast track’ drug candidates and speed up the FDA approval process (the ‘FDA Emergency Use Authorization for Promising Medical Countermeasures Under Development’) (U.S. White House, 2003).

All in all, in 2002 the U.S. dedicated nearly $6 billion to biodefense initiatives for the 2003 budget – a 300% increase from the previous year (U.S. DHS, 2004). Even the NIH’s National Institute of Allergy and Infectious Diseases (NIAID) – a program that has traditionally dealt with non-defense-related initiatives – was awarded $85 million under Project BioShield for research into ‘human immunity and biodefense’ (U.S. NIH, 2003).

In programs such as these, we see several themes coming together which characterize the post-9-11 era of national and homeland security. One of these is the emphasis on bioscience research, especially in the areas of genetic engineering, immunology, and the possible linkages to the emerging fields of genomics, proteomics, and genetic diagnostics.

The ability to sequence the genomes of pathogens is seen by many scientists as the important first step to understanding how those pathogens are able to mutate and infect healthy cells. But alongside this there is also an equal emphasis on the technological infrastructure that enables federal, state, and local health officials to communicate and make decisions in response to possible health crises (U.S. DHS, 2004). This infrastructure includes computer databases and networks (e.g. hospital informatics, up-to-date diagnostic technologies, emergency communications systems), as well as drug production and distribution systems, and the training of health care personnel. In the broadest sense, ‘information’ plays a key role in enabling the communication of health-related data, be it via teleconferencing, via patient-specific data being uploaded to a server, or via the rapid distribution of drugs from the U.S. Strategic National Pharmaceutical Stockpile.

Yet, from the U.S. perspective, an emphasis on biology and information is only part of the equation. At all levels, the ability of government to respond to an emergency is crucial for the biological and informatic components of biodefense to operate in an effective manner. This is where the particular philosophy of war adopted by the U.S. has come into play, and it is a philosophy in the sense that, at the same time that familiar Cold War concepts are deployed (a pharmaceutical ‘stockpile’ or scenarios involving a ‘dirty bomb’), U.S. policy has ontologically redefined war along the lines of terrorism; that is, terrorism as precisely a series of non-catastrophic but highly threatening events. In this sense not only is all terrorism bioterrorism, but we may be witnessing a new definition of ‘life itself’ in which terror exists virtually in relation to life. What might this mean, for terror to exist virtually in relation to life? For one thing, it means that the use of the metaphor of war to talk about disease has ceased to be a metaphor, and that the biological affair of intentionally causing or of fighting disease is literally, in bioterrorism, a form of war.

Submitted by
Christopher Tingus
Harwich (Cape Cod), MA 02645 USA

Comment by Christopher Tingus

November 1, 2014 @ 11:01 pm

“Any excuse will serve a tyrant”
? Aesop

Persuasion rather than force of government upon those individuals who (may) have been exposed in some manner to Ebola with emphasis to seek prerequisite medical advice if any such symptoms occur and to stay isolated and resting rather than expose others……God Bless us all!

Christopher Tingus
Harwich (Cape Cod), MA 02645

Comment by William R. Cumming

November 2, 2014 @ 8:50 am

Thanks for great comments. How many M.D.s employed by all levels of government not as contractors but as employyees? How many as contractors?

Any attending the INFECTIOUS DISEASE conference in NOLA?

Pingback by Prepper News Watch for November 3, 2014 | The Preparedness Podcast

November 3, 2014 @ 1:31 pm

[…] Ebola source sitrep 3 […]

Comment by Christopher Tingus

November 3, 2014 @ 10:36 pm

Far more dangerous and especially as folks are being slaughtered now by ISIS is the following story which we all hope has no fact, however if this eight year resident of the White House is tired, well, step down! Ebola and ISIS are important to us! After all, you signed up and you are the Commander of the Chief! Keep marching straight forward!

Trump: Pres. Obama ‘looks like he’s tired of the job’
Published October 06, 2014 | On the Record

Pingback by Homeland Security Watch » Local conditions, globalized consequences

November 6, 2014 @ 12:10 am

[…] leading Liberian news outlet.  The story was reported by Stephen D. Kollie. As previously noted in Ebola Source Sitrep 3, there seems to have been an unexpected slowing of the Liberian rate of transmission. There are new […]

Pingback by Homeland Security Watch » Ebola source sitrep 4

November 8, 2014 @ 6:07 am

[…] As reported last week, the transmission growth rate in West Africa has slowed for hardest-hit Liberia.  It is increasing in Sierra Leone and Guinea.  There has — apparently — been successful containment elsewhere.  According to Friday’s special update by the World Health Organization the total numbers for Liberia, Sierra Leone, and Guinea are 13,241 confirmed cases and 4950 deaths. […]

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