Unidentified person looking at a computer screen showing a world map of outbreak areas
Source: Patrick Assalé/Unsplash

Broadening the Public Health Security Agenda

Read: Biothreat Preparedness – Less Talking, More Doing, by Catherine Feinman

Listen to Podcast: Public Health – How Prepared Is the Nation?, by Patrick P. Rose

Midway into 2014, public health emergencies around the world pepper local news headlines and raise concern for U.S. residents. Some biological incidents capture the broader attention of the public, for example: the novel emerging infectious disease Middle East respiratory syndrome coronavirus (MERS-CoV) in the Kingdom of Saudi Arabia; the Ebola hemorrhagic fever virus epidemic in western Africa; or the seemingly continuous threat from influenza virus out of Asia. Others remain a sidebar in the news, such as: the chikungunya virus epidemics in eastern Africa and the Caribbean; or the current dengue virus epidemic in the 2014 Soccer World Cup and 2016 Olympics host nation Brazil.

However, none of these threats is far beyond the reach of domestic borders. Few pharmaceutical interventions exist for many endemic infectious diseases that continue to spread beyond previously isolated/neglected geographic regions. Even fewer pharmaceutical interventions, if any, exist for emerging infectious diseases such as MERS-CoV. Often the painful consequence of unavailable pharmaceuticals, if other nonpharmaceutical interventions are not immediately applied, is significant morbidity and/or mortality. Given the nature of some of these diseases with either a high mortality rate – the estimated mortality rates for MERS-CoV and Ebola are 30-60 percent and 59-90 percent, respectively – or significant morbidity rate, the effect is felt well beyond public health institutions and hospitals.

What is intensifying the threat is that, for many diseases, the vulnerable population expands beyond the immunocompromised, the children, and the elderly. Some of these diseases have been aggressively reaching healthy members of society, including front-line healthcare workers, who are raising concerns that these disease outbreaks may severely stress the workforce and, subsequently, the critical infrastructure.

The Threat of Complacency & Disillusion

Public health agencies abroad, assisted through international collaboration, race against the clock to mitigate the destruction caused by these threats through voluntary quarantine/isolation, social distancing, and medical intervention. Despite best efforts, the sheer magnitude of these public health emergencies is overwhelming the response capacities and leading to further spread of disease. The first two cases of individuals infected with MERS-CoV arrived in the United States in May 2014 after traveling on transatlantic flights with hundreds of other passengers. Arguably, there has not been the mass influx of patients with MERS-CoV despite the millions of people taking the pilgrimage to holy sites in the Kingdom of Saudi Arabia.

There also has not been the anticipated spread of secondary cases of persons throughout the United States after having traveled to the region – despite the fact that, in the Kingdom of Saudi Arabia, up to 75 percent of all new infections reportedly occur through secondary exposure. With only two U.S. cases confirmed to date, the threat may seem minimal; however, there is a risk of complacency. Unlike any other natural or manmade threats, biological agents have the capability to evolve and alter their disease transmission. Over time, these pathogens can rapidly and unexpectedly change transmission patterns. Similar to a wildfire blazing through newly discovered dry bush, a pathogen can race through a previously unexposed population after reaching other parts of the world.

The consequences of most disasters are tangible and often measured in the cost of infrastructure destruction. The effect of a public health emergency is not measured the same way because the destruction does not have the same level of visibility. Houses do not crumble, and key infrastructure does not immediately fail. Instead, the consequence of a public health disaster is measured in lives permanently disabled by the disease or lives lost.

For most other types of catastrophes, there are measurable efforts to buy down risk – for example, improved tornado-resistant shelters, higher levies and/or dams for flooding or hurricane-driven flood surge, or better screening procedures for improvised explosive devices. Initiatives to increase resilience against public health threats – expanding hospital surge capacity or investing in specialized medical equipment and supplies – are far less visible and sometimes even more costly, but they also are necessary. Different parts of the United States regularly face a variety of natural disasters, such as hurricanes, tornadoes, or wildfires. At the same time, every part of the United States faces the threat of a public health disaster as ports of entry invite travelers from around the globe.

Actual incidents of public health disasters that have directly affected the U.S. population have been rare. Thus, reconciling investments in increased public health security can be difficult for those not immediately involved in the efforts to stem the effects of the next disease outbreak. As a result, the nation’s preparedness levels are below expected capabilities – with uneducated responses, understaffed healthcare system, and limited response plans – to appropriately respond to a public health disaster. Moreover, existing response efforts reflect little, if any, understanding of how complex and distinct disease outbreaks can be.

Unlike any other type of disaster, the range of scenarios in a public health disaster is rather large, and operational constraints change depending on the type of disease outbreak. It is, therefore, enormously important to have constant situational awareness and remain vigilant of ongoing disease outbreaks everywhere. Overwhelmed and underprepared response officials inevitably resort to ineffective measures – for example, closing national borders as Africa did in March 2014 following an Ebola outbreak – hoping to presumptuously curtail the threat to their jurisdictions.

Connecting the Dots to Save Lives

A new push has recently been initiated to raise the stakes that public health emergencies are in every way as serious of a threat as other natural or manmade disasters. The international community, though not necessarily as a whole, acknowledges that public health security is an increasingly serious vulnerability and that borders or oceans do not limit this vulnerability. Efforts such as the Global Health Security Agenda underscore the importance of a collaborative effort to increase public health preparedness, but this effort should not be limited to looking beyond domestic borders. State and local agencies often take the lead in detecting and responding to domestic biological incidents. Subsequently, these same agencies are the first to enact response measures to mitigate further spread where, in many cases, additional support in the form of manpower or supplies from other sources is limited or unavailable.

From a domestic preparedness perspective, it is important to develop appropriate plans for potential response needs following a public health emergency anywhere in the world. State and locals also need to take the lead in demonstrating that a whole of government approach with a standard operating procedure can best apply limited resources toward saving lives. Improving domestic public health preparedness requires coordinating with law enforcement, customs and border protection, emergency managers, along with public health officials.

Detection and prevention at this level increase the chance of significantly reducing the effect of a disease outbreak, regardless of available resources. With natural disasters seemingly on the rise as a whole, integrating public health security investments connects the dots to an overall higher all-hazards preparedness level. Satellite and radar technology can detect a hurricane several days or more in advance, but the next deadly wave of MERS-CoV may have already begun.

The views expressed in this article are those of the author and do not necessarily represent the position or policy of Gryphon Scientific, LLC.

Patrick P. Rose

Patrick P. Rose, director for pandemic and catastrophic preparedness at the National Association of County and City Health Officials, holds a Ph.D. in infectious diseases and is a subject matter expert on national security issues related to public health security. He works with federal and local stakeholders to address requirements and gaps that produce vulnerabilities in public health security. In addition, he supports efforts domestically and internationally in the field and at the policy level to reduce the proliferation of biological weapons and to increase public health security awareness. These efforts include promoting greater engagement in the Global Health Security Agenda. He is an alumnus of the Emerging Leaders in Biosecurity Initiative and serves as an adjunct assistant professor at the University of Maryland Department of Epidemiology and Public Health.



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