Homeland Security Watch

News and analysis of critical issues in homeland security

December 18, 2014

Ebola update

Filed under: Biosecurity,Preparedness and Response,Public Health & Medical Care — by Philip J. Palin on December 18, 2014

The December 17, WHO situation update is available here.  According to this report, some progress is being made in Sierra Leone, which has replaced Liberia as the nation reporting the most incidents of transmission.

EVD transmission remains intense in Sierra Leone, with 327 new confirmed cases reported in the week to 14 December. While there are signs from the country situation reports that the increase in incidence has slowed and the incidence may no longer be increasing, the country reported the highest number of confirmed cases in epidemiological week 50. 

A major effort was undertaken this week in Sierra Leone to alter population behaviors that are contributing to continued transmission of the disease.  The Guardian (London) reports on some of the strategies being employed.

Reuters has an update on operations as of Wednesday.

UPDATE:

On Friday the Washington Post — which has done distinguished reporting on  the Ebola outbreak in West Africa — published a big front page feature on the situation in Sierra Leone.

Also on Friday NPR interviewed the CDC Director who is the midst of a site visit to West Africa.  Dr. Thomas Frieden warns of the risk that the virus might become endemic and therefore a perpetual source of recurring spikes in transmission.

December 17, 2014

A new homeland security-related blog: The Bifurcated Needle

Filed under: Biosecurity,Media,Public Health & Medical Care — by Arnold Bogis on December 17, 2014

I fell behind on some work this week and am not likely to post anything substantial today, so unfortunately I cannot personally provide Phil reading material to go along with his (really early) morning coffee.

However, for his and everyone else’s reading pleasure I’d like to point out a new homeland security blog that has recently come to my attention: The Bifurcated Needle. Named for the needle used to administer smallpox vaccinations, technically it is a health security blog. Since it seems no one can agree on what means “homeland security” I’m eagerly dragging the “Needle” down to HLS Watch’s level.

It is published by the good, and very smart, folks at the UPMC Center for Health Security. Health security is not unlike homeland security in that it covers a vast intellectual space. They already have posts up covering topics such as measuring preparedness, the security risks involved in virus research, collateral benefits of nuclear power plant preparedness, and the difficulties of biological decontamination.

Very likely worth your time to check it out: http://www.bifurcatedneedle.com/

 

 

December 11, 2014

Going the wrong way in Sierra Leone

Filed under: Biosecurity,Preparedness and Response,Public Health & Medical Care — by Philip J. Palin on December 11, 2014

Eboa 12_10

Ebola concentrations in West Africa.

The map comes from the December 10 WHO Situation Update.  Also from this report is a very troublesome finding, highlighted below.

Effective contact tracing ensures that the reported and registered contacts of confirmed EVD cases are visited daily to monitor the onset of symptoms during the 21-day incubation period of the Ebola virus. Contacts presenting symptoms should be promptly isolated, tested for EVD, and if necessary treated, to prevent further disease transmission.

During the week of 1 December, 95% of all registered contacts were visited on a daily basis in Guinea, 96% in Liberia, and 84% in Sierra Leone (a steady decline since week 44, during which 94% of registered contacts were reached). However, the proportion of contacts reached was lower in many districts. Each district is reported to have at least one contact-tracing team in place.

On average, 17 contacts were listed per new case in Guinea during the week to 1 December, 22 in Liberia, and 6 in Sierra Leone.

December 4, 2014

100,000 Doors

Filed under: Biosecurity,Preparedness and Response,Public Health & Medical Care,Strategy — by Philip J. Palin on December 4, 2014

Recently my non-blogging life has experienced a set of interesting, but time-consuming convergences.  As a result my engagement at HLSWatch will be constrained for several weeks, potentially a few months.  

In my judgment the task of this blog is to amplify, aggregate, analyze and occasionally advocate.  Until more time emerges from the convergence, I will mostly use this Thursday post to amplify a situation someone else has written about, but that has not gotten much mainstream attention.

The Ebola threat continues to be deadly in West Africa and despite considerable progress still presents a potential threat to global health.  Here is the December 3 WHO Situation Update.

Local (whether Dallas or Monrovia) and global engagement of this threat has also been an interesting case-study in prevention, preparedness, mitigation, response, and — we hope — recovery.  It has been fascinating, at least to me, how crucial “whole community” engagement has been to bending the transmission curve.  

For reasons that are not yet entirely clear, Liberia and Guinea have made much more progress on changing population behaviors than has Sierra Leone.  This is despite considerable efforts by the Freetown government for a period of several months.  On Black Friday the New York Times ran a related story on its front page.  The following is from Tuesday’s Concord Times, a leading newspaper in Sierra Leone. It was written by Mohamed Massaquoi.

–+–

The Disaster Management Department in the Office of National Security, with support from UNDP, will be embarking on a door-to-door campaign in new Ebola epicentres across the country, targeting 100,000 households in the next two weeks in Waterloo, Port Loko and Moyamba with specific life-saving information.

The campaign, which is expected to reach one million people, has commenced following the recruitment and training of 300 community disaster management volunteers in Moyamba last week.

The volunteers, drawn from localities in new Ebola epicentres, will disseminate information ranging from the importance of early treatment, keeping families safe from infection while waiting for help, to welcoming survivors back into the community as a way of reducing stigma associated with Ebola.

The UNDP-supported campaign is part of national efforts to engender behaviour change in order to stem the spread of the Ebola virus disease in Sierra Leone.

In the past 21 days, Sierra Leone has recorded an exponential rise in the number of Ebola infections. Latest WHO figures show that while reported case incidence is stable in Guinea with 148 confirmed cases reported in the week to 23 November, stable or declining in Liberia – 67 new confirmed cases in the week to 23 November, Sierra Leone recorded 385 new confirmed cases in the week to 23 November.

In addition to the continued rise of cases of Ebola in Sierra Leone, the epicentre of the outbreak has shifted from the east of the country (Kailahun and Kenema) to the north-west, including Bombali, iron ore mining district of Port Loko and the Western Area, especially Waterloo and Freetown.

The Western Area continues to have the highest rate of infection, with 280 cumulative cases in the past week. Port Loko is also a major area of concern, with 120 cases in the past 7 days, according to WHO figures.

Chief Alimamy Bethembeng II of Waterloo, himself a volunteer in the door-to-door campaign in his community, enthused that with the right information, using face-to-face methods and using people who are part of the community, things would hopefully change. “We have to defend our communities from Ebola,” he said as he moved from house-to-house in the Faya-Mambo neighbourhood in Waterloo, one of the worst hit areas in the Western Area.

During one of the training sessions in Port Loko, Director of Disaster Management Department, Mary Mye-Kamara, said that the face-to-face campaign has proved very successful in slums across Freetown, and that it is the preferred method for effective awareness-raising on Ebola.

She said: “People in some of these communities are still suspicious of outsiders coming into their neighbourhoods and villages telling them about Ebola. Some of them think that these outsiders are the ones spreading the virus. This is why we are engaging the local people, training them so that they will do the awareness raising themselves. That is the only way forward now.”

She added: “Without community ownership this is difficult, even impossible to make any meaningful headway. The imams need to understand and accept that they cannot be doing the same burial rites like before…otherwise the virus will spread.”

Mye-Kamara noted further that denial is still very high, as is distrust and reticence in communities, thus urging everyone to get involved in the campaign.

“People said to us why should they be bothered to take their sick relatives to the hospital and treatment centres when the ones who had been taken before did not return? ‘They are going to die anyway’. But now we are saying to our compatriots that, with early treatment, there is a huge chance of survival. We are showing them evidence of people who have recovered from the virus. They are seeing it and we continue to hope things will change. Ebola will go,” she said.

Denial, suspicion about the spread of the disease, low level of knowledge and information are still very much prevalent especially among the poor in urban and rural areas. The face-to-face campaign hopes to target the hard-to-reach villages and communities with the right information in Port Loko, Moyamba and Waterloo in particularly, where the virus is spreading.

UNDP Programme Manager Saskia Marijnissen says, “Stopping the Ebola outbreak will not only depend on improved knowledge, but also on a change in attitude and practices. Our approach actively engages community members in a dialogue to motivate behaviour change.”

November 20, 2014

Ebola — no sitrep — but an update

Filed under: Biosecurity,Preparedness and Response,Public Health & Medical Care — by Philip J. Palin on November 20, 2014

One Wednesday the World Health Organization released a new update on the situation in West Africa.  The rate of new transmissions has continued to decline in Liberia and Guinea.  But the curve is continuing upward in Sierra Leone.

I have not seen a persuasive analysis to explain the difference between the three neighboring nations.  But there is some indication that too many social-networks in Sierra Leona may still be in denial.  Community engagement and organization are widely thought to be what turned-the-curve in Liberia.

On Tuesday a subcommittee of the House Foreign Affairs Committee held a hearing on fighting Ebola in West Africa.   You can see/hear a video of the hearing and read the prepared testimony at the committee’s website.

I probably will not prepare a new sitrep this weekend as I have the last few weekends.  A couple of new “day job” assignments are going to take a serious commitment through mid-February.  I may be a bit AWOL from HLSWatch.  We’ll see.

November 15, 2014

Ebola source sitrep 5

Filed under: Biosecurity,Public Health & Medical Care,Strategy — by Philip J. Palin on November 15, 2014

The number of deaths traced to the current Ebola outbreak now exceeds 5000.  The rate of transmission has not increased in Guinea and has slowed in Liberia. But the situation in Sierra Leone is continuing to worsen.  A new network of Ebola cases has emerged in Mali among health workers who were exposed while caring for a man with kidney failure.  The patient was also suffering from a non-diagnosed Ebola infection.

Ebola_November 14

The fatality rate among those exposed to the Ebola virus is falling. In June the fatality rate for this West African outbreak was estimated at 90 percent.  In September the fatality rate was still at least seventy percent.  In prior Ebola outbreaks — much smaller in scope — the fatality rate has averaged 50 percent of those infected.   There are some studies that suggest with early intervention the fatality rate is now as low as 25 percent.

These are small and still unconfirmed studies.  But on a preliminary basis it is reasonable to observe:

  • The amount of circulating viral load was higher in those who died than in survivors; those patients with the highest levels of virus were most likely to die.
  • One of the strongest determinants of survival appears to be patient age. Patients older than 40 years were nearly 3.5 times more likely to die than those aged less than 40. The association between an older age and a higher risk of death was found regardless of whether the patient had co-morbidities or not.
  • Evidence of substantial fluid loss and profound electrolyte derangement associated with severe diarrhoea appears to increase the risk of a fatal outcome. More aggressive supportive care, especially intravenous rehydration, is thought to improve the prospects of survival.

Seriously compromising the ability to provide early diagnosis and care is a public health infrastructure insufficient to conduct the necessary contact-tracing. According to the November 12 WHO update:

Between 3 and 8 November, 5301 new contacts were identified in Guinea, Liberia and Sierra Leone, compared with 4067 new contacts traced in the previouwoulds week. A total of 95% (124,214 of 130,140) of required daily contact visits were conducted. However, the proportion of contacts reached was lower in many districts. Each district is reported to have at least one contact-tracing team in place. On average, only 10 contacts were listed per case in the three countries in the past week. The low average number of contacts listed per case suggests that the estimate of 95% gives an unduly favourable view of the success of contact tracing. Active case finding teams are being mobilized as a complementary case detection strategy.

The situation in West Africa remains very bad, but it is not — yet? — as bad as some projected in September or even early October. The predictions have, in part, been disrupted by increased public health interventions, improved clinical care, and — especially — altered population behavior.  While the threat of the virus was too long underplayed, since August a creative and committed response has paid-off.

In recognition of the continuing high risks, Médecins Sans Frontières (MSF), an NGO with deep experience in the region, has recommended a new strategic approach, “Agile and well-equipped rapid response teams should be deployed quickly to actively investigate hotspots wherever they occur, and mount a comprehensive response.” This approach would depend much less on the construction and operation of isolation-and-treatment centers.

The rainy season is coming to an end in West Africa.  Typically the dry season sees a substantial increase in population movements.  This increased mobility will threaten the fragile progress that has been made.  The current ten-day forecast for Monrovia predicts almost daily rain and thunderstorms.  But early December is predicted to be bright and sunny.

Meeting early today in Brisbane the G20 affirmed and expanded commitments to fight Ebola in West Africa.  The world’s leading economies also signaled that more needs to be done to prevent and mitigate infectious threats much worse than Ebola: “This outbreak illustrates the urgency of addressing longer-term systemic issues and gaps in capability, preparedness and response capacity that expose the global economy to the impacts of infectious disease.”

November 8, 2014

Ebola source sitrep 4

Filed under: Biosecurity,Public Health & Medical Care,Strategy — by Philip J. Palin on November 8, 2014

This series of sitreps was initiated in midst of a media frenzy over the mishandling of an Ebola patient in Dallas. Yesterday Dallas was officially declared Ebola free.

In mid-October the nation seemed transfixed by symptoms and almost entirely distracted from their source.

In the intervening weeks there has been distinguished original reporting of the Ebola crisis by the New York Times and National Public Radio.  I have been less impressed with television news coverage.  But this Sunday, Sixty Minutes, the CBS news program, has scheduled a special report on The Ebola Hot Zone (2 minute video preview). Check your local listings.

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.

Ebola Comparison

Click to open larger image.  Source: WHO November 5 Update

I have not seen a credible explanation for the recent divergence between Sierra Leona’s and Liberia’s transmission rates.  Guinea’s so far less virulent outbreak is probably a matter of geography, population density, and transportation networks.

As noted below, progress is being made on several aspects of the Ebola response strategy.

Ebola Mesures

Later today the USAID-US Army mission in Liberia will open its first Ebola Treatment Unit.

But clearly there remains much to be done.  The European Union has pledged over 1 billion Euros, but other than the Brits in Sierra Leone and the French in Guinea, actual engagement has been slow. On Thursday a Dutch ship departed Rotterdam loaded with ambulances, mobile hospitals, laboratories and other equipment. The cargo has been provided by nine EU Member States and UNICEF.

On Wednesday President Obama requested a special appropriation of $6.1 billion to address both domestic and international response to Ebola.  The Senate Appropriations Committee will begin hearings on the request on November 12.  The House Appropriations Committee is expected to follow suit before the end of the month.

November 6, 2014

Local conditions, globalized consequences

Filed under: Biosecurity,Preparedness and Response,Public Health & Medical Care,Strategy — by Philip J. Palin on November 6, 2014

The following appeared in the November 3 edition of FrontPageAfrica, a 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 reports this week, however, of increased transmission rates in neighboring Sierra Leone.  Here is the most recent WHO update.

There has been a remarkable absence of US broadcast media attention to Ebola as most of those treated for the disease in the United States have survived.  The “press” — digital and paper — has been much more attentive.

Late yesterday, President Obama requested a $6.18 billion special appropriation to combat Ebola.  According to the White House website, the funds will be used to

  • Fortify domestic public health and health care systems
  • Contain and mitigate the epidemic in West Africa
  • Speed the development and testing of vaccines and therapeutics
  • Establishing the capacity of vulnerable countries to prevent, detect, and respond to disease outbreaks before they become epidemics that threaten the American people.

–+–

Vahun, Lofa County - Barely seven months after the deadly Ebola Virus hit Lofa County, Liberia’s fourth most populated county (2008 national census) life seems to be returning to normal, but fear that the disease will resurface, exists among residents of the county. Schools remain closed, nonessential staffs working for the government; continue to remain home, while the culture of handshake, hugging and all forms of bodily contact is still prohibited.

At the crossing point, which connects Lofa and Bong counties, travelers are compelled by security officers to get of vehicles, wash their hands and undergo temperature screening. Those with high temperature levels are prevented from entering the Lofa County and refer to the local health authority for additional medical checks.

In Voinjama, the provincial capital of the county, posters of Ebola awareness messages are prevalent. Community radio stations still boom with anti-Ebola songs and messages. This, they say, is to remind residents that Ebola epidemic is not over yet. Many, including non-government agencies believe the disease spread because people did not believe in the existence of the virus.

“No one could listen when it was announced that Ebola is in town,” said Isaac Ballah, a local NGO worker in Voinjama City. Ballah told FrontPage Africa that nearly everyone in the city came to terms with the disease when a man showing signs and symptoms of the virus was seen lying at the entrance of the Lofa County Community college.

Ballah narrates that the suspected Ebola patient was lying helpless, vomiting and openly defecating as locals went to take a glimpse at the first apparent case, which signaled the coming of dark days. “After that morning, we all went home silently, with so much worried. The next day everyone picked up their clorax bottles and we stopped shaking hands and touching each other,” he said. “Few weeks later you could only hear the sound of ambulances everywhere and at the same time, see two to three pickups filled with dead bodies.”

All this epitomized the agony the people of the county were subjected to for months said Ballah. But for several weeks now, not many cases relating to the Ebola virus have been reported in the county. But residents are still taking safety seriously to prevent any widespread occurrence of the disease. They are skeptical in ruling out a new outbreak considering the county’s closeness to neighboring Guinea and Sierra Leone with which it shares borders.

Nationwide, the numbers in Ebola cases seems to be declining as has been acknowledged by the World Health Organization (WHO). The WHOs Bruce Aylward on Wednesday confirmed the decline in the number of Ebola cases in Liberia.

“The actual number of newly reported cases is beginning to decline in Liberia and the government is driving a multi prone investigation, looking at multiple strands of evidence to try and understand, is this real, is this reporting phenomenon or is this care seeking phenomenal that’s changing? So far based on the information received today… it appears that the trend is real in Liberia,” he said.

Despite this good news authorities and citizens of Lofa are taking the good news with a bit of caution. In Voinjama, all general markets remain closed to prevent public gathering. Residents are forced to sell their produce during regular weekdays instead of Fridays, which is recognized as the official market day.

Zangota’s Patient zero

In Zangota, a small town just 45 mins from Voinjama City, where over thirty deaths were reported, the Ebola nightmare began with Krubo Mamaie, who traveled to the town for medication, says 33 year-old Luana Korvah, a mental health supervisor who was actively working with the county’s Ebola task force.

According to Korvah, Mamie had cared for her sick husband in Voinjama who died of Ebola and later left for her town when she also fell ill. She was referred to the Konia Health Center by local officials in Zangota, but died en route to the Foya Ebola Treatment Center because her condition had turned for the worse.

Said Korvah: “She and her husband had burial activities in Guinea, when they went back into the community the husband fell sick.” “She was then caring for the husband and later the man died. They took the man to Letisu for burial and those that took part in the burial ceremony, who did the bathing and all the other traditional things died.”

Korvah said many residents in the area did not believe it was Ebola rather they held the general opinion that their wells were poisoned and thus causing them diarrhea and other illnesses. The residents’ failure to accept the virus existence left nearly 70 persons dead in Zangota and the numbers continued to increase spreading to nearby towns and villages.

Now, after nearly eight months battling the deadly virus, it seems Ebola has taught many lessons in the county. Precautionary measures are the order of the day. Hand washing, no handshake is just a few preventive methods that are still being religiously practiced even though infections have slowed in a County which has lost nearly 200 persons.

Careful barbing

At a local barbing shop in central Voinjama, barbers use hand gloves, bleach and other disinfectant before barbing. Not many people are allowed to sit in the barbing shop to avoid bodily contact. “We are still scared and are doing everything possible to ensure that no one get infected in this shop,” Mohammed Sore, owner of the two brothers barbing shop told FPA.

He says while there has been no case of Ebola reported in the county for the past few weeks, he and his colleagues have not stopped the preventive measures and will continue until the country is declared Ebola free. “We will stop using the gloves and chlorine when we hear that Ebola is not in the country again,” said one of our fears is that we are close to the border and people are still coming in from Guinea,” he said Sow.

At the over 80-bed facility run by the medical charity group Medicines Sans Frontieres in Foya, all patients have been discharged with zero cases reported so far. All schools in the county remain closed as part of President Ellen Johnson Sirleaf’s directive on the prevailing state of emergency in the country.

Non-governmental Organizations such as the Pentecostal Mission Unlimited (PMU Liberia) is moving in to help with preventive materials and support to many health facilities, as residents wait quietly to see a total eradication of the deadly disease. Residents of Lofa have seen hell; Ebola killed and obliterated entire families. Cultural and religious practices helped to rapidly spread the disease among community members who were also in strong denial of the virus according to residents.

Now, the numbers of cases being reported are few and no much news of suspected deaths in Lofa County. Hand washing buckets are still placed in nearly every household and those that cannot afford the bucket travel with a bottle of chlorine water just for protection against the deadly virus, which has killed a total of 2413 persons and infected 6535 individuals in Liberia alone.

Harvard Public Health School and Reuters: Ebola fear, not science, driving policies

Filed under: Biosecurity,Media,Public Health & Medical Care,Risk Assessment — by Arnold Bogis on November 6, 2014

The news agency Reuters and the Harvard School of Public Health have a partnership to produce “Health Watch,” which according to the School’s website is: “a web series featuring expert analyses and comments about the latest developments in health news. This series is presented by The Forum at HSPH and the Harvard School of Public Health in collaboration with Reuters.”

In this episode, “Dr. Paul Biddinger, Associate Director of the Harvard School of Public Health Center for Public Health Preparedness, tells Reuters that fear is driving certain non-science based policies like the involuntary quarantine of health workers.” Dr. Biddinger also directs the School’s Emergency Preparedness and Response Exercise Program.

 

November 5, 2014

RIP Former Boston Mayor Thomas Menino: The Public Health Mayor

This week Boston laid to rest it’s longest serving mayor, Thomas Menino.  He served as mayor in Boston for 20 years.  Yes. That’s right.  Twenty years.

To his admirers he was known as the “Urban Mechanic,” as the Boston Globe describes, ”leaving to others the lofty rhetoric of Boston as the Athens of America, he took a decidedly ground-level view of the city on a hill, earning himself a nickname for his intense focus on the nuts and bolts of everyday life.” To some of his detractors (and even his supporters) he was referred to as “Mumbles,” for his less than soaring rhetorical skills.

This humble man from the Hyde Park neighborhood of Boston rose to national prominence, with former President Bill Clinton paying his respects before the funeral procession and Vice President Joe Biden attending the ceremony. Impressive for a politician recognized to have no political ambition beyond running his city.

What does this have to do with homeland security? For some time I’ve heard from various colleagues that preparedness, particularly health-related preparedness, had an unusual amount of political support in Boston. Public health and EMS were not simply the minor leagues to law enforcement and fire service major league players. But it became vivid when I read the following description from a food-orientated homage to Mayor Menino from The Atlantic food critic Corby Kummer:

But aside from the coddling and special treatment any mayor who shows up gets, Menino cared about food for exactly the reasons today’s food-movement activists do, and long before it was fashionable to embrace what food can and should mean: access to fresh produce for everyone of every income level; gardens as ways to unite and repair communities; and, most importantly, fresh food as a route to better health. The mayor told everyone, including his biographer, longtime Atlantic senior editor Jack Beatty, that he wanted to be remembered as “the public-health mayor.” That made him work particularly closely with my spouse, John Auerbach, who served 10 years as Boston’s health commissioner. 

So….apparently I missed this self-appointment.  After the fact it was easy to find further evidence of Menino’s interest in public health.  See the videos I’ve posted below.

Again, how is this related to homeland security? Two points that at least I think of are interest. 

 

A lot, if not the majority, of public health work does not seem to fall into the category of homeland security. Expanding access to fresh produce in low income communities, anti-smoking efforts, childhood vaccination campaigns, etc.  It’s not always about responding to the next Ebola outbreak.  Yet when taken as a whole, improving the health of the community in general improves overall resilience.  Healthy people fare better during and following disasters than unhealthy ones.  People with access to health insurance are more likely to visit a primary care doctor than the emergency room for common maladies, thereby not taking up vital resources during events like the Boston Marathon bombing. A healthier community is a more resilient community.

Menino’s attention to public health underscores the importance of political leaders in homeland security. I have often heard professionals complain about meddling politicians (along with the annoying press) and how events can be run more smoothly when they are absent.  Yet not only do they play an important role in communicating with the public during and following disasters, they make or influence the choices made in a community before there is a bad day.  Menino’s focus on public health not only improved the overall health of Bostonians, but contributed to the competence exhibited during the response to the Marathon bombing, from the existence of a Medical Intelligence Center to the cooperation between city agencies such as Boston EMS and Public Health with the private hospital systems.

It is comparing apples and oranges, but in thinking about this I could not help but contrast Boston’s situation with that of New York City.  Size and resource issues aside, NYC has spent the most energy on security instead of general preparedness since 9/11.  I am not arguing that there has not been a lot of resources directed towards preparedness and response activities and organizations, only that it is lacking when compared with the radical changes enacted in the NYPD and other agencies charged with preventing a terrorist attack. I think I could make the case that Boston, under Menino’s leadership, took a more all hazards approach while NYC, under Mayors Giuliani and Bloomberg, remained primarily focused on terrorism. That is not a value judgement, but simply an observation.

If you are interested, the following video highlights many of Mayor Menino’s accomplishments in public health.  From the Boston Public Health Commission (which Menino created in 1996):

 

If you have a little more time, here is a longer discussion held at Harvard’s School of Public Health with Menino shortly after he left the Mayor’s office.  For those more security minded, at the beginning of the discussion he is asked and replies with a lengthy description of his point of view about the events surrounding the Boston Marathon bombing.

 

 

 

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.

October 30, 2014

No Ebola sitrep yet

Filed under: Biosecurity,Public Health & Medical Care — by Philip J. Palin on October 30, 2014

As of early Wednesday morning the WHO had not released updated data on the Ebola transmission rate in West Africa.  Given the rest of my life, I have to pound out a post before 0900 on October 29 if I am to get you anything on October 30. There are related reports that I might share, but it is probably more helpful to minimize my contribution to the noise level until some meaningful signal is available.

UPDATE

Late on Wednesday afternoon WHO released an update.  Here it is.  Received too late for my further analysis.

By the way, trying to seriously follow major trends and events in order to have something to write to you each Thursday is a very helpful intellectual and temporal discipline.  I would not know half what I know about Ebola if I was not trying to fulfill my relationship with you.  Thank you.

October 26, 2014

Embracing diversity

Filed under: Biosecurity,Border Security,Preparedness and Response,Public Health & Medical Care,Strategy — by Philip J. Palin on October 26, 2014

obama pham(Official White House Photo by Pete Souza)

None of us much like what we perceive as mixed messages.  But many of us seek out diverse sources of information.

I am — as regular readers know too well — a big fan of diversity.  It is an intellectual and aesthetic preference, almost certainly a personality predisposition.

Diversity is also a key characteristic of resilience.  The more diverse a system the less prone it is to catastrophic collapse, the more creative combinations that exist the more likely the system (or sub-system) is to resist and, if necessary, rebound from challenges.

I am personally skeptical of most efforts to reduce variance, increase consistency, and especially any tendency to reserve decisions for some centralized authority.  I am aware such approaches can generate benefits.  But there are also trade-offs and I perceive we too often accept the trade-offs without recognizing what we are giving away.

Since Thursday I’ve been in Newark and New York.  The confirmation of Ebola in a physician who returned to New York after treating patients in West Africa has caused concern.  On Friday Governors Christie and Cuomo, acting more on their political instincts for advancing the common good than expert medical advice, announced a strict quarantine requirement for health care workers returning to JFK and Newark International airports.  This exceeds federal requirements. (Illinois soon followed for those arriving from West Africa into O’Hare.)

I was busy, but as I watched the local news a bit and read the reports I was pleased to see this diversity emerge.  I like it when state and local leaders exercise their best judgment and authority.  I respect political judgment, especially when it relates more to how human social systems actually operate and less about the next election.  I found the non-partisan, reasoned rhetoric of the Governors and Mayor de Blasio mostly helpful.  Medical therapies and social therapies can diverge.

At just about the same time, or at least during the same news cycle, President Obama was purposefully — and a bit awkwardly to my eyes — hugging nurse Nina Pham (above) who has recovered from the Ebola she contracted at her hospital in Dallas.  The intended message was, I hope, clear enough.  For the more literal minded, the President followed up explicitly in his weekly media message.

Meanwhile… Kaci Hickox a nurse arriving at Newark from Sierra Leone, asymptomatic, and according to a preliminary test virus-free, is nonetheless being kept in a 21-day quarantine against her will.  She writes in the Saturday Dallas Morning News:

I am a nurse who has just returned to the U.S. after working with Doctors Without Borders in Sierra Leone – an Ebola-affected country. I have been quarantined in New Jersey. This is not a situation I would wish on anyone, and I am scared for those who will follow me.

I am scared about how health care workers will be treated at airports when they declare that they have been fighting Ebola in West Africa. I am scared that, like me, they will arrive and see a frenzy of disorganization, fear and, most frightening, quarantine… (The nurse continues with a rather horrific story of her welcome to the United States.  You should read it.)

The epidemic continues to ravage West Africa. Recently, the World Health Organization announced that as many as 15,000 people have died from Ebola. We need more health care workers to help fight the epidemic in West Africa.  The U.S. must treat returning health care workers with dignity and humanity.

The ACLU has announced it will take action challenging the New Jersey quarantine order.

Then as if to put into even sharper contrast the different angles on reality alive in Trenton, Albany, and Washington DC, on Sunday morning I read our UN Ambassador Samantha Power is in West Africa.  She has already visited the Ebola wards.  Should she be quarantined in isolation on her return?  Or in deference to separation of powers, will a sanitary cordon of the Ambassador’s residence at the Waldorf be sufficient?

Thursday and Friday I was mostly impressed with how New York local-media was handling the story. Saturday I was too otherwise engaged to notice. Now early on Sunday morning there is a nearly palpable urgency to take sides… or, if one does not feel confident/competent to choose sides, to bitterly complain regarding the incompetence of the “authorities” who should have had this sort of risk fully thought-through.  ”It’s not tight”, the President himself has complained.

In my experience reality is seldom tight. At a certain point working to make it tight strips the threads and even breaks the head.  Can we learn to engage diversity affirmatively, creatively, even systematically, as a potentially positive — in any case, persistent — aspect of reality?  In dealing with complex risks, I have found this to be an especially productive option.

MONDAY UPDATE:

According to several news sources, New York will “loosen” its screening protocols.  Here’s a bit of the AP report:

Gov. Cuomo back peddled Sunday on his insistence that medical workers returning to New York from Ebola-stricken countries would have to undergo a mandatory 21-day quarantine at a government-regulated facility

The governor, in a joint news conference with Mayor Bill de Blasio, said health care workers and citizens who have had exposure to Ebola patients in West Africa will be asked to stay in their homes for the 21-day quarantine.

During the 21 days, the quarantined person will be checked on twice a day by health care professionals to take their temperature and evaluate their condition, Cuomo said.

Here’s the official statement from the Governor’s office.

Constant change in response to feedback, adapting to new information (new expressions of reality) is another feature of diverse and resilient systems.  And just to be clear: in the most resilient systems while change is constant a core-coherence persists.  Which highlights the big difference between consistent and coherent, between control and collaboration…

SECOND UPDATE:

According to NJ.com and other news outlets, Nurse Kaci Hickox will now be allowed to quarantine at home in the state of Maine. The New Jersey Governor’s office released a transcript and video to provide context for this shift.

October 23, 2014

Ebola source sitrep 2

Filed under: Biosecurity,Preparedness and Response,Public Health & Medical Care — by Philip J. Palin on October 23, 2014

This is the second in an irregular update on efforts to slow and eventually stop the rate of Ebola virus transmission in west Africa.  The risk of transmission in the United States is a function of the rate of transmission at the source.

It is important to acknowledge issues with data quality.  Over the weekend a piece in Science magazine noted, “… it’s widely known that the real situation is much worse than the numbers show because many cases don’t make it into the official statistics. Underreporting occurs in every disease outbreak anywhere, but keeping track of Ebola in Guinea, Liberia, and Sierra Leone has been particularly difficult. And (as) the epidemic unfolds, underreporting appears to be getting worse.”

Still the data that is collected can help us understand some broad dynamics of transmission.

Yesterday afternoon — October 22 — the World Health Organization released a progress report on their response roadmap.  It provides details through the end of last week for all known cases of Ebola, but focuses primarily on the situation in Guinea, Sierra Leone, and Liberia.  Following is a timetable for transmission of the virus in Liberia and metropolitan Monrovia. Similar charts are available for Guinea and Sierra Leone in the online report.  The report also provides updates on treatment centers and other interventions underway.

WHO_liberiaClicking on the image will generate a larger version

CITYA.M., the City of London business publication, has produced a helpful visual analysis of the Ebola outbreak in Liberia, so far the hardest hit of the the three nations at the epicenter of the outbreak.  These maps communicate the crucial role that population density plays in transmission. They also suggest how the virus moved along human networks from the index case in southeastern Guinea into Lofa County and quickly to the economic/social/political center of metropolitan Monrovia.

Liberia density and number

Liberia per 100,000

MORE from CITYA.M.

While US media focus on early indications that transmission has been contained in the Dallas case, at least as important is the news that the Nigerian public health system has successfully contained an initial set of transmissions in densely urban Lagos.  Fundamental to this Nigerian success was a well-organized existing public health infrastructure and network of human expertise. An effective anti-polio process was essentially repurposed to rapidly contain a new infectious threat. Strategically it is important to recognize this was the adaptation of an existing capacity, not an ad-hoc insertion of a special or reserve capability.

According to the Associated Press, in Nigeria “Health workers tracked down nearly 100 percent of those who had contact with the infected, paying 18,500 visits to 894 people.”

The absence of such an existing capacity has been a principal cause of the outbreak in Liberia and its neighbors.  Sunday U.S. Army Maj. Gen. Gary J. Volesky, commanding general of the 101st Airbone Division and his thirty member command team arrived in Monrovia to assume leadership of DOD contributions to Operation United Assistance. The Army is sending approximately 700 Soldiers from the 101st, including members of the division headquarters staff, sustainment brigade, combat support hospital and a military police battalion. Another 700 troops will be deployed from multiple engineering units to build 17 100-bed medical treatment units and a 25-bed hospital. MORE.

New cases of transmission in Nigeria — the United States and elsewhere — are likely.  Until we can bend the exponential growth of transmission in Liberia, Sierra Leone, and Guinea, a networked and increasingly densely populated planet will be vulnerable.  (A few hours after the original version of this post appeared, a new case of Ebola was confirmed in New York City.)

The Foreign Affairs Council of the European Union met on Tuesday.  Despite some additional progress, the readiness and urgency of the European response will depend on the results of a summit of EU leaders that opens today in Brussels.

October 19, 2014

Who is my neighbor?

Filed under: Biosecurity,Preparedness and Response,Public Health & Medical Care,Strategy — by Philip J. Palin on October 19, 2014

EBOLA_James harris

I perceive it is prudent — as well as accurate — to make the case that the best way to mitigate Ebola risk in the United States is to significantly degrade the risk in West Africa.

Recently Thomas Frieden, Director of the CDC, felt it was politically necessary to say, “I am not protecting West Africa. My number one responsibility is to protect Americans from threats.”

Over the last few weeks at HLSWatch we had cause to consider the potentially warping effects of self-interest too narrowly conceived or fatally denied.

Last week The Telegraph (London) offered a gallery of online photographs entitled, “Survivors: Portraits of Liberians who recovered from Ebola“.  Above is James Harris, age 29, who recovered after two weeks at death’s door.  He is now a nurse’s assistant in a Doctors Without Borders treatment center in Paynesville, Liberia.

October 18, 2014

Ebola source sitrep 1

Filed under: Biosecurity,Preparedness and Response,Public Health & Medical Care — by Philip J. Palin on October 18, 2014

This is the first in an irregular update on efforts to engage Ebola’s center-of-gravity.  As noted previously, I am concerned US media is not giving sufficient attention to fighting this disease where it matters most for all of us.

If the rate of transmission can be suppressed at the source, then the risk to the United States will be substantially mitigated.  If the rate of transmission in West Africa cannot be significantly reversed in the next 60-to-90 days some epidemiologists are concerned Ebola will establish itself well outside it’s historically native range.

Data collection in Guinea, Sierra Leone, and Liberia — the current outbreak’s epicenter — is far from state-of-the-art.  But following is the best information now available from local health agencies as aggregated by the World Health Organization:

Ebola Chart

These numbers will get worse — probably much worse — before they get better.  Current projections suggest 10,000 new cases per week by December.

But there is also some encouraging news.  The Ebola transmission cycle in Senegal and Nigeria has evidently been successfully interrupted and contained.

Ebola survivors who have developed an immunity to the disease are now involved in caring for other patients and may be the source of life-saving blood transfusions.

Population behaviors, such as burial practices, are adapting to the risk.

Several new treatment centers are under construction.  Early identification, isolation, and effective treatment of those with Ebola will cut transmission rates and improve survival rates.  This week US military operations to expand local capacity got seriously underway. (Further details)

There will, almost certainly, be more cases of Ebola presenting in the United States.  The best way to reduce vulnerability is to eliminate the threat at its source.

 –+–

Editorial Note:  It has long been my personal opinion that “homeland security” is most meaningful when it offers its legacy professions, policy-makers, and the public a strategically integrated angle on risk.  The risk environment is usually complicated, often complex and even chaotic.  There are important roles for an array of specializations, threat-specific strategies, operational expertise, and tactical competence.  Homeland security will be more successful to the extent it is well-informed of these related domains.  But homeland security delivers added-value when it can stitch together these diverse elements into a coherent — ideally mutually amplifying — whole.  Strategy, at least in my use of the term, is especially concerned with how risks can be intentionally engaged in a manner that deploys the threat against itself and reduces self-generated vulnerabilities.

What is the most effective strategy for the risk of Ebola?

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