With the current amount of discussion and media coverage regarding the spreading Zika virus and the mounting concerns over antibiotic drug resistance, public health remains a critical homeland security and emergency preparedness priority. Unfortunately, it is often a fluctuating priority that does not receive consistent attention, action, and funding to prepare for future known and unknown public health threats.
The May 2016 birth of a child in the continental United States reportedly with microcephaly from the Zika virus has once again pushed the subject of preparedness and funding for public health into the op-ed pages and 24-hour news cycle. As Ebola receded in Africa and faded from discourse in the United States, Zika erupted due to its reported grave effects on pregnant women and their developing fetuses. As a result, the public health emergency fund in the United States and its level of funding were once again a topic of intense discussion and political squabbling.
Beyond these current public health challenges and funding questions, another question arises about whether cross-sector planning and preparedness priorities are being properly addressed for the whole of community requirements to prepare for, respond to, and recover from a severe public health threat. Previous research, observations, and experience may not provide the highest level of confidence for a unified response to rapidly emerging and evolving pathogenic threats.
Changing Focus From Ebola to Zika
The international priorities and focus continue to transition from the diminishing Ebola virus to the expanding Zika virus and other re-emerging public health concerns such as yellow fever. Director General of the World Health Organization Dr. Margaret Chanentified numerous international public health and policy issues for the world during her address to the 69th World Health Assembly in May 2016, which included the following statements:
“Drug-resistant pathogens, including the growing number of ‘superbugs,’ travel well internationally in people, animals, and food.”
“The Ebola outbreak in three small countries paralyzed the world with fear and travel constraints.”
“For Ebola, it was the absence of even the most basic infrastructures and capacities for surveillance, diagnosis, infection control, and clinical care, unaided by any vaccines or specific treatments.”
“The rapidly evolving outbreak of Zika warns us that an old disease that slumbered for six decades in Africa and Asia can suddenly wake up on a new continent to cause a global health emergency.”
“For Zika, we are again taken by surprise, with no vaccines and no reliable and widely available diagnostic tests.”
“Few health threats are local anymore. And few health threats can be managed by the health sector acting alone.”
“Medicines for treating chronic conditions are more profitable than a short course of antibiotics.”
“For infectious diseases, you cannot trust the past when planning for the future.”
The Zika virus is not new, but expanding to new locations beyond Africa and Asia largely due to international trade and travel. The virus was originally isolated and identified in a sentinel rhesus monkey in the Zika Forest near Entebbe, Uganda, in 1947. Although unknown how and when Zika arrived in Brazil, it has been theorized that the virus may have been introduced during a sporting event in August 2014 with numerous competitors from four Pacific nations where the virus was present. This theory compounds concerns regarding the upcoming Olympic Games and several recently completed international events in Brazil.
Unfortunately, confusion may exist regarding the definite source of an illness and the most appropriate medical treatments. As with Zika and other viruses, the effectiveness and usefulness of broad antibiotic use for an unconfirmed illness, which may be viral, can have significant consequences for the whole society – especially with the explosion of antibiotic-resistant superbugs.
Expanding Resistance to Antibiotics
In May 2016, The Review on Antimicrobial Resistance issued, “Tackling Drug-Resistant Infections Globally: Final Report and Recommendations.” The report, sponsored by the United Kingdom and Wellcome Trust, estimated that 10 million lives per year would be at risk by 2050 due to the rise of drug-resistant infections. These antimicrobial drugs include antibiotics, antivirals, antifungals, and antimalarials. According to the study, less than five percent of venture capital investments in pharmaceutical research and development between 2003 and 2013 were for antimicrobial development. The reportentified 10 interventions or fronts to reduce the demand for antimicrobials, including better incentives to promote investments for new drugs and improvements of existing ones.
The recent finding that an E. coli bacterium superbug, with the mcr-1 gene, was resistant to the last-resort antibiotic colistin only added to the concerns about resistance and the nation’s future capabilities. According to the Centers for Disease Control and Prevention, the mcr-1 gene exists on a plasmid, a small piece of DNA that is capable of moving from one bacterium to another, spreading antibiotic resistance among bacterial species. Colistin was reportedly seldom used in humans due to its toxicity, but it has reportedly been utilized in the agriculture environment for decades.
Due to the enormous costs of developing new medicines and treatments, the amount of new antibiotics in the research pipeline appears rather small compared to other drugs. There are reportedly stronger financial incentives to invest in drugs for chronic diseases to recoup research investments over a long period of time. A May 2016 analysis by The Economist magazine revealed the limited cumulative profits from antibiotic research from pre-clinical research to off-patent sales.
In May 2016, the World Health Organization issued a research and development blueprint for actions to prevent epidemics. The global strategy and preparedness plan was created to reduce the amount of time required to deliver tests, vaccines, and medicines, and to strengthen emergency response during epidemics and pandemics.
Epidemic & Pandemic Preparedness
It has been estimated that as many as 100 million people died during the Spanish Flu pandemic outbreak in 1918. It is projected that a similar pandemic outbreak today could result in the death of 360 million people around the world despite the availability of vaccines and antimicrobials. In addition to the world population growth, the pace of urbanization, globalization, and travel only expands the genuine concern for the rapid spread of epidemics and pandemics.
In the November 2013 DomPrep Bio-Training edition, the subject of preparing for Black Swan pandemic and biological threats asked important questions regarding preparedness for a vast array of public health threats. Sadly, many of the same critical questions remain unanswered today, such as, “Have the many lessons from SARS, H5N1, H1N1, MERS, and Ebola truly been learned and implemented?”
Unfortunately, too many still view a pandemic-prone pathogen as the primary responsibility of the public health and medical services organizations. Law enforcement, military, and numerous other public and private sector organizations have critical responsibilities to execute during a serious public health event – usually in close coordination and collaboration with the other agencies involved for support and response.
As is true of many significant incidents and disasters, there is usually very little if any time to plan and prepare when a new threat suddenly appears, rapidly expands, and eventually overwhelms medical services and public health officials. In addition, quarantine, isolation, and medical countermeasure dispensing procedures may be required to contain a new disease outbreak or biological agent attack and, in some situations, any subsequent public unrest. The experience with Ebola in 2014 in the United States and other recent outbreaks does not indicate a significant level of readiness and coordination. Many of the most controversial and difficult issues have been ignored since the Ebola outbreak.
Need to Prepare & Respond
Ebola and Zika were not new public health threats, but viruses that were isolated to rather limited areas due to emergence, transmission, and travel limitations. The geographic isolation and infrequent outbreaks may have led to international complacency. Globalization has provided many benefits for the world, but unfortunately there are also grim consequences such as the rapid spreading of novel and re-emerging pathogens.
The prospect of a very serious novel virus with sustained human-to-human transmission could make previous Ebola or Zika outbreaks appear as rather manageable challenges in a globalized world. This concern was well established in journalist David Quammen’s 2012 book, “Spillover: Animal Infections and the Next Human Pandemic.” He characterized spillover as the moment when a pathogen passes from one species to another. This subject is very important since, in 2005, reportedly three-quarters of emergent pathogens were zoonotic spillovers. It is necessary to be cognizant of spillover public health threats that are both highly infectious and highly contagious, which could greatly threaten global health security.
As concluded by the Council on Foreign Relations in May 2016 regarding the future of global health security:
“Creating a sustainable and coordinated environment for supporting innovation is key to advancing the goal of improved global health security. This is true whether it is investing in ‘just-in-case’ preparedness or a ‘just-in-time’ response to an outbreak. Implementing the hard-learned lessons from the last decade in global health can help achieve this goal while ensuring that the assets, resources, and commitments of partners across various sectors all fully contribute to enhancing global security.”
These public health challenges and threats linger and evolve with little notice and many cascading consequences. The question remains about whether planning and preparedness will get ahead of these current public health threats and the ones on the horizon, or the nation will continue to respond the best way that it can and only add Ebola and Zika to the list with SARS, H5N1, H1N1, MERS, and many others pathogens – with lessons not truly learned. It is necessary to evolve faster than these public health threats – a difficult but critical necessity for global health security.
The opinions expressed herein are solely those of the author in his individual capacity, and do not necessarily represent the views of his agency, department or the United States government.