Publications

The US government has made sustained biodefense-related investments in basic and applied R&D aimed at producing anti-Ebola MCMs for more than a decade. Investments made by the National Institute of Allergy and Infectious Diseases (NIAID), through Biodefense and Emerging Infectious Diseases Program funding, and by the Department of Defense (DoD) Defense Threat Reduction Agency (DTRA), through the Chemical and Biological Defense Program (CBDP), have led to the development of a majority of the countermeasures in the pipeline. In addition, biodefense investments in building advanced development capabilities at the Biomedical Advanced Research and Development Authority (BARDA) and in building mechanisms for emergency clinical testing and emergency regulatory approval at the Food and Drug Administration (FDA) are now proving critical to current efforts to rapidly confirm safety and efficacy and ramp up production of countermeasures.

This article describes adoption by local health departments (LHDs) of federally recommended participatory approaches to public health emergency preparedness and LHD organizational characteristics associated with more intense community engagement in emergency preparedness, a top priority for US national health security.

Smallpox was one of the worst diseases that ever plagued humankind. From the time of the pharaohs until the 20^th century, it was a continuous scourge, killing 30 percent of those who were infected, and disfiguring most of the afflicted. The ability to vaccinate against it, and to use vaccine to diminish its spread, culminated in the eradication of smallpox. In 1980, the World Health Organization (WHO) declared that smallpox was no longer causing infections and that vaccinations could cease.

The UPMC Center for Health Security is grateful for the opportunity to provide comments on the ethical issues related to public health emergency response that have arisen as a result of the Ebola Virus epidemic in West Africa. The following comments reflect the collective views of several staff members of our organization but do not necessarily represent the views of all our staff and do not necessarily represent the official views of UPMC. We address each of the 7 issues posed in the Request for Comment.

Singapore is a critical security partner to the US in Southeast Asia. The US and Singapore share longstanding military relations, with American forces making use of Singapore’s Naval Base facilities, contributing to peace and stabilizing efforts throughout the region, offering humanitarian assistance, and acting as a deterrent to potential security threats.1 US-Singaporean security cooperation also extends to bilateral exercises, joint military training activities, and cargo screening efforts. The importance of Singapore to biosecurity in Southeast Asia continues to grow, due to its rapid biotechnology growth, its leadership in biosafety training within the region, its experience in containing the pandemic of severe acute respiratory syndrome (SARS), as well as ongoing preparedness efforts related to new, emerging diseases. 

Research on highly pathogenic organisms is crucial for medicine and public health, and we strongly support it. This work creates a foundation of new knowledge that provides critical insights around the world’s most deadly infectious diseases, and it can lay groundwork for the future development of new diagnostics, medicines, and vaccines. Almost all such research can be performed in ways that pose negligible or no risk of epidemic or global spread of a novel pathogen. However, research that aims to create new potential pandemic pathogens (PPP) (1)—novel microbes that combine likely human virulence with likely efficient transmission in humans—is an exception to that rule. While this research represents a tiny portion of the experimental work done in infectious disease research, it poses extraordinary potential risks to the public.

Half of the US population lives in close proximity to the nation’s 65 nuclear power plants. The safety of the communities living in the Emergency Planning Zones (EPZs) encircling these nuclear power plants has long been the subject of debate. For example, the size of an EPZ and the scope of emergency planning around nuclear power plants are challenged (Thomas et al. 2011; Government Accountability Office 2013). This debate intensified after the nuclear disaster in Fukushima stressed the framework for nuclear disaster response, leading some to recommend an evaluation of planning in the US (UPMC Center for Health Security 2012; U.S. Nuclear Agency 2013).

Cases of Ebola that have turned up in Dallas and New York City have prompted calls for a travel ban to prohibit travelers from Sierra Leone, Liberia, and Guinea from entering the US during the ongoing Ebola outbreak. But travel bans have not worked in past epidemics and will not stop Ebola from spreading. Banning travel would slow the movement of people and goods to those countries, harm the international response to the outbreak in West Africa, and increase the prospect of ongoing global spread of Ebola. In addition, travel bans could lead to complete isolation of those 3 countries and would further worsen the economic and humanitarian toll of this crisis.

Managing any contagious infectious disease outbreak involves breaking the chain of transmission from those who are infected with the pathogen to those who are not. Not all pathogens, however, are equal in their contagiousness, and considerable variation exists.

The viral disease measles, for example, is considered to be one of the most contagious human diseases. Its high rate of contagion is driven by 2 attributes: the ability to spread through the air via small particles (ie, airborne transmission) and the fact that one of the symptoms of measles is coughing, an effective means of expelling those particles. On average, a person infected with measles can infect 15 other people through the course of his or her illness. Diseases like tetanus and anthrax, on the other hand, are not contagious at all because they lack the ability to spread between humans. In between these 2 extremes lie all the other infectious diseases.

In considering how to weigh the risks and benefits of synthetic biology, Kaebnick, Gusmano, and Murray pose the question of whether there is scientific research that should not be funded or performed or if there are potentially dangerous results that should not be widely disseminated.¹ Such questions, they propose, require a new set of rules and norms for knowledge generation—an “ethics of knowledge.”² They identify two examples of research that might fall into a nonpermissible category, including “research that is aimed at producing and disseminating knowledge of . . . how to produce more dangerous forms of H5N1 and smallpox.” There are already rules and norms to guide the funding and generation of scientific knowledge, however, including research on influenza and smallpox. Even if more rules and guidance were added to the practice of science, potentially problematic, “dual-use” research would still occur, and as a practical matter, it is unlikely that results from those studies can be contained, particularly if the research is of wide interest.

Contemporary cost estimates of dengue fever are difficult to attain in many countries in which the disease is endemic. By applying publicly available health care costs and wage data to recently available country-level estimates of dengue incidence, we estimate the total cost of dengue to be nearly 40 billion dollars in 2011.

Since December 2013, an outbreak of Ebola virus disease in the West African nation of Guinea has rapidly evolved into a humanitarian crisis of unforeseen proportions, overwhelming vulnerable communities in Liberia, Sierra Leone, Nigeria, and Senegal. While previous outbreaks of Ebola cumulatively resulted in 2,486 cases and 1,590 deaths, the current Ebola epidemic has so far resulted in 8,376 infections and claimed 4,024 lives (as of October 10, 2014), prompting the World Health Organization (WHO) to designate it as a public health emergency of international concern.1,2 Officials from the US Centers for Disease Control and Prevention (CDC) estimate that, in the absence of public health interventions, Liberia and Sierra Leone could experience as many as 550,000 cases (or 1.4 million after correcting for underreporting) by January 2015.

The size of the world’s largest Ebola outbreak now ongoing in West Africa makes clear that further exportation of Ebola virus disease to other parts of the world will remain a real possibility for the indefinite future. Clinicians outside of West Africa, particularly those who work in emergency medicine, critical care, infectious diseases, and infection control, should be familiar with the fundamentals of Ebola virus disease, including its diagnosis, treatment, and control. In this article we provide basic information on the Ebola virus and its epidemiology and microbiology. We also describe previous outbreaks and draw comparisons to the current outbreak with a focus on the public health measures that have controlled past outbreaks. We review the pathophysiology and clinical features of the disease, highlighting diagnosis, treatment, and hospital infection control issues that are relevant to practicing clinicians. We reference official guidance and point out where important uncertainty or controversy exists.

The objectives of the Global Health Security Agenda (GHSA) will require not only a “One Health” approach to counter natural disease threats against humans, animals, and the environment, but also a security focus to counter deliberate threats to human, animal, and agricultural health and to nations' economies. We have termed this merged approach “One Health Security.” It will require the integration of professionals with expertise in security, law enforcement, and intelligence to join the veterinary, agricultural, environmental, and human health experts essential to One Health and the GHSA. Working across such different professions, which occasionally have conflicting aims and different professional cultures, poses multiple challenges, but a multidisciplinary and multisectoral approach is necessary to prevent disease threats; detect them as early as possible (when responses are likely to be most effective); and, in the case of deliberate threats, find who may be responsible. This article describes 2 project areas that exemplify One Health Security that were presented at a workshop in January 2014: the US government and private industry efforts to reduce vulnerabilities to foreign animal diseases, especially foot-and-mouth disease; and AniBioThreat, an EU project to counter deliberate threats to agriculture by raising awareness and implementing prevention and response policies and practices.

The Global Health Security Agenda (GHSA) was launched in February 2014 by the US government in partnership with more than 25 other governments, the World Health Organization (WHO), the World Organisation for Animal Health, and the Food and Agriculture Organization of the United Nations. The GHSA aims to accelerate progress toward a world prepared to counter major infectious disease threats and to focus greater political attention on the need to promote global health security as an international priority. 

The critically ill are a unique group of patients in disaster response as they require resource-intensive care, need advanced and costly therapies, and require specialized settings and providers to deliver this care(1-2). They can present with a sudden surge of patients over a short period of time, pushing the limits of the healthcare facility, or they can present over a sustained period of time, such as the 2009 H1N1 pandemic, straining the larger regional health-system.

Previous articles in this series have provided funding information for federal civilian biodefense programs and programs focused on radiological and nuclear preparedness and consequence management. This year the authors have expanded the focus of the analysis to US federal funding for health security. This article provides proposed funding amounts for FY2015, estimated amounts for FY2014, and actual amounts for FY2010 through FY2013 in 5 domains critical to health security: biodefense programs, radiological and nuclear programs, chemical programs, pandemic influenza and emerging infectious disease programs, and multiple-hazard and preparedness programs.

The current outbreak of Ebola in West Africa—a region that has been largely devoid of visitations from this virus—has sparked many news stories and fueled speculation about how such outbreaks are started, sustained, and eventually controlled. However, with some important caveats, this outbreak displays many of the characteristics of prior outbreaks, the first of which occurred in 1976.

From October 22 to 31, 2012, Hurricane Sandy affected 14 US states and Washington, DC, causing particularly severe damage in New York and New Jersey. It was the second costliest hurricane in US history and caused 43 deaths in New York City and tens of thousands of injuries. When Sandy hit New York City on October 29, 2012, the flooding and power outages led to the evacuation of residents, hospitals, nursing homes, and assisted living facilities. New York City hospitals and various government agencies evacuated approximately 6,300 patients from 37 health care facilities. . . . Despite robust preparedness efforts, the severity of Sandy caught New York City hospitals by surprise because major hospital evacuations were not anticipated. Widespread power outages forced hospitals to rely on backup generators, which subsequently failed because of flooding. When health care facilities evacuated, neighboring institutions received the displaced patients. . . . We sought to use a structured, narrative-based approach to describe the effect Hurricane Sandy hospital evacuees had on hospitals and the strategies that facilitated their response.

Dual-use concerns—that legitimate research has the potential to be misused—are inherent in life sciences research. In the past 15 years, numerous scientific papers have raised security questions, and split opinions of scientists, ethicists, and policymakers on whether the research should have been performed or published. Some of the most high-profile examples include the addition of an immunomodulatory gene into the mousepox virus genome, which made the mousepox vaccine ineffective (and suggested that similar manipulations to the smallpox virus genome could make the smallpox vaccine ineffective); the synthesis of poliovirus, the 1918 influenza strain, and the synthesis of a bacterial cell; and “gain of function” (GOF) work on influenza viruses to explore whether H5N1 and other strains have the potential to become transmissible in humans.(1-6) Given the increasing ease of manipulating and synthesizing genetic material, and the continued expansion of biological research globally, additional dual-use concerns are certain to arise in the future.