Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 141
6
The Challenges to
Post-Eradication Outbreaks
OVERVIEW
As the United States enters the post-eradication era, it is critical that we
develop thoughtful institutional strategies to meet the challenges of poten-
tial reintroduction or re-emergence of disease. The waning of surveillance
and laboratory diagnostic capability, reduced medical awareness, lack of
vaccine supply and production capacity, limiter! institutional response ca-
pacity, decreased immunity in the population at large, and increased threats
of bioterrorism all leave the non-immunized populace highly vulnerable to
a post-eradication outbreak. Planning for the post-eradication era will likely
warrant consideration of major outbreak scenarios and the requires! capac-
ity for response.
Hospitals serve as a major hub in the U.S. health care system ant! can
and should play a major role in an outbreak response. However, they have
neither the capacity nor infrastructure to handle such a crisis, and there are
no financial incentives or mandates in place to encourage them to devote
efforts to anticipate potential outbreak scenarios. There is an enormous
amount of work to be done to prepare hospitals for the post-eradication
era.
Because of the increasing threat of bioterrorism, especially with regard
to smallpox, planning for potential outbreaks in a post-eradication era
should involve consideration of national security implications in addition
to public health considerations. Although health care workers would be the
sentinels of any outbreak response, no matter what the security implica-
141
OCR for page 142
142
CONSIDERATIONS FOR VIRAL DISEASE ERADICATION
tions, a bioterrorist act may require the involvement of other communities,
such as intelligence and defense and arms control, that may not typically be
involved in outbreak response. The appropriate agencies and institutions
must be prepared to offer a swift and effective collaborative response.
Preparing for unexpected disease outbreaks also requires a flexible and
adaptive post-eradication vaccine program involving continued vaccine pro-
duction, research, and development. Vaccine manufacture must keep up
with changing regulatory requirements (e.g., safety issues concerning the
threat of prior-mediated diseases from animal protein components of vac-
cines), new scientific challenges (e.g., alterations to the virus), and changes
in the manufacturing process.
Institutions must be prepared to deal with the psychological challenges
expected to surface during a post-eradication outbreak, namely, fear and
panic. Well-traineci responder staff, effective communication regarding the
risks of infection and exposure, and a swift, well-coordinated public health
response will be key in promoting a healthy public reaction.
Although U.S. institutions may be starting to take some steps in prepa-
ration for a post-eradication era, much of the developing world lags far
behind. Many countries are not only still struggling with early eradication
initiatives for example, immunizing all children and developing effective
communications networks they are doing so in the face of adversity. Many
developing countries lack not only immunization services but basic health
care services as well, and are in the midst of conflict situations where
vaccinators are being killed in the field.
This issue of equity has increasingly become a component of global
health concerns. Access to limited quantities of vaccines has been debated
as a human rights issue. Within the United States, this focus has been on the
uninsured and underserved populations. More broadly, in developing coun-
tries where the ability to pay for vaccines and maintain appropriate infra-
structure for vaccine delivery remains quite limited- the responsibilities of
international organizations, national governments, development banks, and
private-sector suppliers are raised as a challenging ethical question.
i:
READY OR NOT: THE U.S. HEALTH CARE SYSTEM AND
EMERGING INFECTIONS
Kenneth D. Bloem, M.P.Ho
Senior Fellow, The Johns Hopkins University Center for Biodefense
Studies, Baltimore, MD, and Former CEO, Georgetown University
Medical Center, Washington, DC
The preparedness of the U.S. health care system to respond to future
OCR for page 143
THE CHALLENGES TO POST-ERADICATION OUTBREAKS
143
disease outbreaks accidental or intentional- deserves careful consider-
ation. A caveat may be in order here, however, as this topic will force us to
descend from the Olympian heights of scientific discourse to the arid plains
of bureaucracies, institutions, and politics. This presentation will focus on
hospitals, clinics, and home care agencies what is commonly termed the
"U.S. health care system" as opposed to the public health system, whose
readiness is addressed elsewhere in this report.
To the question, "Are we prepared?" the answer, in my opinion, is
emphatically negative. This lack of readiness is characterized by:
lack of capacity and infrastructure,
lack of incentives and mandates,
absence of networks of collaborating institutions, and
unresolved staffing and legal policy issues.
It is worth noting that there may be legitimate conflicting perspectives
on what role the U.S. health care delivery system should play in response to
an epidemic that constitutes a major public health threat. This paper sup-
ports the notion that the acute health care system can and ought to play a
very important, but delimited, role in helping the nation respond to future
outbreaks. Following is an assessment of the four problems listed above.
Their solutions are critical to an effective health care system response.
Capacity and InEastructure Issues
In order for the health care system to respond effectively to a potential
disease outbreak, the health system must be operating reasonably effec-
tively prior to the outbreak. That is, a certain amount of basic functionality,
organizational infrastructure strength, and extra capacity (i.e., availability
of drugs, equipment, supplies, and personnel) will be a sine qua non of an
effective response. If hospitals and physicians are already struggling to
handle day-to-day operations due to a lack of staff, equipment, and other
core capacities, it will be impossible for them to respond effectively to a
. ... . .
s~gn~cant crisis.
Unfortunately, U.S. hospitals are currently experiencing tremendous
economic pressures. One-third of all hospitals are losing money. Of the
two-thirds that are still profitable, their margins declined by a third be-
tween 1998 and 1999. Their profitability is only 4.7°/O, which is only
slightly above the medical Consumer Price Index (CPI). In addition to the
Balanced Budget Act of 1997, which reduced aggregate hospitals' Medicare
payments by more than Congress intended, hospitals face a host of new
regulatory demands including HIPAA (Health Insurance Portability Act),
which industry analysts estimate will cost the sector more than did Y2K
OCR for page 144
144
CONSIDERATIONS FOR VIRAL DISEASE ERADICATION
preparedness efforts. Other regulatory pressures include ergonomic regula-
tions, patient safety regulations, and major seismic upgrades (for California
hospitals), to cite just a few.
The problems hospitals currently face are not only financial. The most
acute operational issues relate to staff shortages- including nurses, tech-
nologists, pharmacists, technicians, nurses' aides, housekeepers, medical
records coders, and others. Current staff levels are insufficient for hospitals
to cope even with the small and entirely predictable seasonal influenza
epidemics. To cite a few examples:
· In December 1999, during the flu season, three-quarters of the Los
Angeles emergency rooms were so full that, for 10 days, they had to reroute
ambulances to other hospitals.
· In Maryland, the amount of time that hospitals are on "emergency
by-pass" has doubled each year for the past three years.
.
In San Antonio, the city's Emergency Medical Services physician-
director was quoted in a New York Times article by C. Goldberg, "Emer-
gency Crews Wary as Hospitals Say, 'No Vacancy,' " December 17, 2000,
as saying "We're dying; I got called nine times yesterday to divert my
ambulances and that wasn't an unusual day. We've got an epidemic of the
nonavailability of acute care beds, and the epidemic is becoming a pan-
demic."
Because the population is aging and academic enrollments in key health
care professions have declined, most observers are worried that these infra-
structure problems will only become worse. In the same New York Times
article mentioned above, the director of a suburban Boston ER, for ex-
ample, likened ERs to canaries in the coal mine: "We are basically the
canary that's telling the story that the whole system is in trouble, its capac-
ity is inadequate to meet the peak demands."
In addition to chronic infrastructure deficiencies, hospitals lack the
capacity to handle "surges" of new patients. For example, a 1998 survey of
~ . ~ ~ ~ ~ ~ .
medical resources for the state ot Minnesota revealed that only 60 of 144
acute care hospitals only 465 beds state-wide had negative air pressure
rooms, which are critical tools for managing patients with highly conta-
gious diseases (Osterholm and Schwartz, 2000~. As another example, a
recent fire in a downtown high-rise motivated the Maryland Secretary of
Health to commission a study which revealed that the city of Baltimore,
home to two major meclical centers and medical schools, could not handle
a situation involving only 100 casualties needing overnight ventilators
(O'Toole, 2000~.
After two decades of hospital reimbursement policies based exclusively
on market principles, hospitals now operate on a " just in time just what's
OCR for page 145
THE CHALLENGES TO POST-ERADICATION OUTBREAKS
145
required" basis which governs the availability of drugs, supplies, equip-
ment, and staffing. In the process, we have lost sight of the historic concept
of the hospital as a community resource that is always ready in the event of
disease outbreak.
Incentives and Mandates
Among the range of issues with which hospital executives deal on a
daily basis, a potential disease outbreak whether accidental or as a result
of bioterrorism- is a low-probability event that competes for attention
with more pressing, and more certain, matters. Currently, hospitals have
neither incentives, such as funding, to prepare for future outbreaks, nor a
legal mandate to do so.
Since the Reagan administration, the United States' policies governing
hospital reimbursement have been fundamentally free-market-based. This
has led to economic competition among hospitals within a community, as
well as the notion that hospitals that support "issues of the commons" (e.g.,
care for the poor, medical education, biomedical research) without receiv-
ing full reimbursement are doing something "economically irrational."
Spending significant dollars preparing for bioterrorism, or a similar event
on behalf of the community, would trigger a red flag to a hospital's man-
age`1 care payers, who would think they were overpaying (Bentley, 20001.
This does not imply that hospitals would not respond in the event of a
crisis. In fact, American hospitals have a record of extraordinary response
when disaster strikes. The point is that, without preparedness funding, it is
economically irrational to expect or hope for preparatory efforts on the
part of any individual health care organization.
In addition to a lack of incentive for hospitals' preparatory efforts,
there is no mandate requiring such activity. Currently, the closest thing to a
hospital mandate is a Joint Commission on the Accreditation of Health
Care Organizations (TCAHO) requirement that every hospital have emer-
gency plans and drills in place to cover a broad range of potential disasters.
Legal mandates and financial incentives will likely be required to cata-
lyze hospital response on this issue. At least four types of financial protec-
tion will be necessary:
· Funds to help hospitals address fundamental capacity and infra-
structure deficiencies,
· Funds for outbreak response planning and preparedness,
· Compensation for direct patient care in the event of an outbreak,
combined with a loosening of the usual requirements for detailed corrobo-
rating documentation, and
· Reimbursement for extraordinary institutional costs.
OCR for page 146
146
CONSIDERATIONS FOR VIRAL DISEASE ERADICATION
In addition, immunity from liability will be necessary in the context of
actions that outbreak management typically entails: triage decisions, deal-
ing with immuno-suppressed populations, mandatory vaccination, and
quarantine.
Regional Collaborative Networks
An effective community response to an outbreak will require that mul-
tiple health organizations and the public and private sectors respond in a
highly integrated fashion. This collaboration must bridge at least three
distinct health communities—public health, emergency management/first
responders, and medical care delivery—each of which has its own culture,
language, and clecision-making processes. All three communities will need
to be linked with local and state elected and government authorities, law
and order institutions, state laboratories, military hospitals, the Centers for
Disease Control and Prevention (CDC), and other agencies.
However, substantial communications and knowledge barriers exist
within anal among all of these various health agencies. For example, a
recent TOPOFF exercise, named for its engagement of top officials of the
U.S. government, was held in Denver in spring 2000. It tested the readiness
of government officials and agencies to respond to a bioweapons event. In
an assessment of TOPOFF, a number of the participants noted that differ-
ent professions practiced different decision-making processes. One observer
commented that, "In public health, most decision-making is through demo-
cratic processes and consensus-building, but for some decisions, this cannot
work." Another observer remarked, "The time frame that public health is
accustomed to dealing with is not what is needed for bioterrorism. In this
type of crisis, one needs to make decisions quickly. You don't have the
luxury of time to do more research." One public health official noted a
widespread lack of familiarity with terms—such as a lIC ~ loins Information
Center), a fOC (joint Operations Center), or DMORTs (Disaster Mortuary
Assistance Teams) used by the emergency management community
(Inglesby et al., 2001~.
As another example of a communications barrier, during the West Nile
outbreak in New York City in 1999, an infectious disease physician from
one of the boroughs notified the New York City Department of Health
about two suspected cases of encephalitis. In the meantime, 20 other pa-
tients with encephalitis had already been admitted to other NYC hospitals.
Although encephalitis is clearly recognizable and is considered a legally
reportable disease in New York, none of those other 20 cases had been
called in (O'Toole, 2000~. Even if these cases had been called in, the capac-
ity of the health agency to respond adequately is uncertain. Dr. John Bartlett,
Chief of Infectious Disease at Johns Hopkins University School of Medi-
OCR for page 147
THE CHALLENGES TO POST-ERADICATION OUTBREAKS
147
cine, conducted an experiment two years ago in the Hopkins emergency
department, during which he simulated a patient with a case of inhalational
anthrax. During this exercise, which occurred during a summer weekend,
no one he contacted either inside or outside the Hopkins hospital was
certain about which telephone number to use or which state official to
notify (Osterhoim and Schwartz, 2000~. Finally, a call was made to the
state public health officer and an urgent message left on an answering
machine. Due to a lack of beepers in the public health department, the call
was not answered until three days later.
Although the federal government has initiated efforts to create linkages
among the emergency management and public health services in 50 to 60
cities nationwide, no region has yet truly integrated emergency manage-
ment, public health, and medical services. An effective regional network
requires adequate funding, designation of an in-charge organization and
individual, and development of a regional response plan that would need to
be rehearsed, critiqued, and modified as appropriate. Among the many
challenges to overcome are the climate of competition among hospitals,
distrust across the public-/private-sector divide, and communications and
cultural obstacles among the multiple health communities.
Staffing and Legal/Policy Issues
Several groups of hospital executives have assembled over the past year
under the auspices of the Johns Hopkins Center for Civilian Biodefense and
the American Hospital Association (supported by the Department of Health
and Human Services [DHHS ~ Office of Emergency Preparedness). Their
objective has been to identify issues and barriers to hospitals response to
bioterrorism. One set of concerns pertains to hospital staffing, specifically:
· Staff shortages, which cut across multiple professional and non-
professional categories, are national in scope (in the case of nursing, inter-
national) and, given declines in academic enrollments for some professions,
will [likely be long-lasting.
· For many health care professions (including physicians, nurses, and
pharmacists), licensing restrictions prohibit individuals from practicing
across state borders. If unaddressed, this will act as a barrier to importing
physicians and nurses from outside crisis areas.
· Seventy to eighty percent of hospital staff are female, the majority
of whom are heads of households or are responsible for the care of family
members. In the event of a major epidemic, which could last for weeks or
months, the issue of family support becomes critical (Bentley, 2000~.
· Personal protection in the form of immunizations and access to
antibiotics for staff and their families is a critical issue. It is unclear how
OCR for page 148
148
CONSIDERATIONS FOR VIRAL DISEASE ERADICATION
health care staff will respond to future outbreaks, though it may be instruc-
tive to look back at workers' and professionals' concerns during the early
days of the AIDS epidemic.
A second set of concerns pertains to legal issues. For example, the
Emergency Medical Treatment and Labor Act (EMTALA) was designed to
prohibit hospitals from refusing treatment to uninsured patients and send-
ing them to other hospitals. The legislation requires each hospital to screen
and stabilize every patient, even during a disease outbreak when it is likely
that a hospital's emergency room may be closed for containment purposes.
Also, different hospitals may have different roles in a public health emer-
gency; for example, some may be used solely for quarantine, others for
triage, and still others for specialized treatment. Thus, during an outbreak,
not all hospitals may be capable of screening and stabilizing every patient.
The EMTALA was not designed with an era of emerging infections in mind
(Bentley, 20001.
EMTALA may be just the tip of the iceberg of unresolved legal and
public policy issues, many of which relate to the fragmented U.S. legal
system. For example, the legal powers that authorize response in a public
health emergency are divided between the national and local levels. Inter-
estingly, legal power may depend on whether an epidemic is deemed to be
natural or intentional; national security law might apply in the case of the
latter (Fidler, 2000~.
A legal system that emphasizes protection of individual rights, while
restricting government powers from impinging on such rights, creates addi-
tional potential barriers to an effective public health response. For example,
citizens might ignore government orders, such as travel bans, quarantine, or
compulsory treatment directives, which could, in turn, increase the likeli-
hood that military intervention would be necessary to enforce public health
(Fidler, 20001.
Conclusion
It would be inappropriate to conclude without putting into a larger
context the challenge of preparing our health care system to respond to
future epidemics. As previously mentioned, there may be legitimate con-
flicting perspectives on what role the health care system should assume in
the event of a major public health crisis. These perspectives are buttressed
by age-old differences in skill sets and attitudes between the medical and
public health disciplines, and by large cultural gaps between triage and
treatment, containment and continuous quality improvement, and isolation
and architectural openness. A Stanford University Hospital analysis found
that the routine hospitalized patient encounters over 30 different hospital
OCR for page 149
THE CHALLENGES TO POST-ERADICATION OUTBREAKS
149
employees during an average 24-hour period hardly an ideal environment
from which to try to contain an epidemic. Nonetheless, hospitals can and
should play a major role in outbreak response:
· The population will undoubtedly continue to seek hospital care for
diagnosis, treatment, and prophylaxis. The absence of treatment facilities
could contribute to public panic.
· Hospitals are socially and geographically well-established arsenals
within their communities, constituting well-known loci where profession-
als, equipment, supplies, and information technology come together in the
service of local communities.
. < ~
However, it is remarkable how quickly local hospital capacity is over-
whelmed in many, if not all, epidemic-response scenarios. There is a need
for sophisticated modeling of a range of hypothetical outbreaks, using
current hospital capacity data. More importantly, we should explore all
reasonable mechanisms to help hospitals substantially expand their capaci-
ties to handle mass surges of people (by incremental hundreds or even
thousands) in the event of a major epidemic. One option, for example,
might be to create expandable big-containment units, which would be self-
contained but placed adjacent to hospitals. Such units might enable the use
of the existing hospitals' organizational infrastructures, supplies, and per-
sonnel, while providing a simple but epidemiologically sound setting for the
triage and treatment of far more individuals than the institutions' emer-
gency rooms or clinics could safely handle. Similarly, we might explore the
feasibility of training a cadre of hospital-based epidemiologists, current
EMS physicians, and new staff. These suggestions and speculations are
offered as a point of departure for future discussions on how best to help
America's health care system prepare for inevitable disease outbreaks.
VACCINES FOR POST-ELIMINATION CONTINGENCIES
Thomas P. Monath, M.D.
Vice President, Research and Medical Affairs
Acambis Inc., Cambridge, MA
Vaccines have been by far the most efficient means to prevent and
control infectious diseases. Smallpox eradication was achieved through vac-
cination, and the eradication of poliovirus and measles will be achieved
when the prevalence of artificial immunity is sufficiently high to preclude
interhuman transmission. The benefits of disease eradication achieved
through vaccination include life years gained; savings to patients, families,
OCR for page 150
150
CONSIDERATIONS FOR VIRAL DISEASE ERADICATION
and society due to reduced morbidity and mortality; avoidance of costs for
treatment and continued vaccination; indirect cost savings due to increased
productivity; and the freeing-up of health care resources for other interven-
tions. Following successful eradication, a responsible policy must include
provisions for vaccine reserves and contingency planning in case the disease
re-emerges; surveillance and diagnostic activities; and research on and de-
velopment of new vaccines and therapeutic drugs.
Rationale for Vaccine Reserves
Because surveillance and case-finding may be difficult, particularly in
medically underserved regions, disease eradication may be uncertain for
several years after the last reported case. During this period of watchful-
ness, rumors of disease and case and outbreak investigations will continue,
and vaccine must be available in the event of re-emergence. The means by
which a disease could be reintroduced after presumptive elimination are
listed in Table 6-1. For smallpox and other diseases under consideration for
potential elimination—polio, measles, and rubella no enzootic or non-
human reservoir has been identified as a source of reintroduction; thus, the
principal risks are human factors, inadvertent escape of laboratory stocks,
and intentional release (bioterrorism or biowarfare). The consequences of
reintroduction become increasingly grave over time clue to the decline of
herd immunity, susceptibility of the population to a pandemic, senescence
of surveillance and laboratory diagnostic capability, and reduced medical
awareness.
Smallpox as a Case Study
When smallpox was eradicated in 1979, re-emergence was dismissed as
highly unlikely for several reasons:
TABLE 6-1 Sources of Disease Re-Emergence After Eradication
Chronic infection and reactivation (e.g., immunosuppressed hosts)
Natural reservoir or zoonotic cycle
Closely-related agent fills niche of original virus
· Vaccine manufacturer's seed viruses
· Research laboratory stocks
· Stored diagnostic specimens
.
.
.
releases
Cross-contaminated or mislabeled laboratory materials
Environmental sources, fomites, human remains (e.g., permafrost)
Biological weapons, surreptitious stocks, accidents, weapons tests, intentional
OCR for page 151
THE CHALLENGES TO POST-ERADICATION OUTBREAKS
151
· There was no enzootic reservoir; monkeypox and other zoonotic
poxviruses related to the smallpox virus were not considered a significant
source for the reintroduction of human pox virus.
· There were only a limited number of laboratories working with
smallpox, and confidence was high that all laboratory stocks had been
identified and destroyed. Reference materials were deposited in only two
laboratories, one in the United States and the other in the Soviet Union.
· There was no evidence that smallpox virus could persist or be
reactivated in previously infected humans.
There was a high degree of confidence that vaccine reserves (ap-
proximately 200 million doses deposited at WHO) were adequate for any
contingency and vaccine manufacture could be reinstated if necessary.
· There was lithe concern about any threat posed by biowarfare
(BW).
In the United States, vaccine manufacture ceased in 1982, and immuni-
zation of soldiers ceased in 1989 (Table 6-2~.
Smallpox was dismissed as a bioweapon in part because all countries,
including the USSR, had participated actively in eradication of the disease.
It was, therefore, a surprise to {earn that the Soviet Union, a nation engaged
in the eradication effort, would simultaneously engage in surreptitious,
state-sanctioned activities that could result in disease reintroduction. More-
over, smallpox has undesirable features as a bioweapon for several reasons:
the disease is easily diagnosed; attribution of an attack would be obvious;
the virus is transmissible and could backfire on non-target populations; the
incubation period is long and its effect on a target population delayed; and
a vaccine is available and routinely used to protect military forces.
The fallacy of these conclusions was not apparent until the early l990s,
after a defector from the former USSR revealed that smallpox was consid-
ered a strategic (not tactical) weapon. Development of smallpox as a BW
TABLE 6-2 Smallpox Vaccination History, United States
1949 Last indigenous cases of smallpox (Texas)
1969-1970 Studies emphasize high incidence of vaccine-related adverse events
1971-1972 Routine vaccination of children ceases
1976 Vaccination of medical workers ceases
1979 Eradication certified by WHO
1982 Wyeth ceases vaccine manufacture
1989 U.S. military ceases vaccination of soldiers
2000 Over half the U.S. population unvaccinated
Vulnerability to pandemic spread if reintroduced
OCR for page 162
162
CONSIDERATIONS FOR VIRAL DISEASE ERADICATION
the biowarfare potential of measles. Measles is transmitted by respiratory
droplets and is highly contagious. It can remain infective in droplet form in
air for several hours, especially in low relative humidity (CDC, 1992), and
can be transmitted by airborne spread as aerosolized droplet nuclei. Under
these conditions, it is possible that a biowarfare aerosol release of measles
virus could result in infection in exposed, non-immune individuals. Measles
causes significant morbidity and mortality in children and is even more
severe in aclults. In one study, 30°/O of aclult cases exhibited bacterial super-
infection of the respiratory tract, 17% exhibited evidence of bronchospasm,
and 3°/O developed pneumonia requiring hospitalization (Gremillion and
Crawford, 1981~.
The biowarfare potential of measles would probably figure promi-
nently into the defense community's assessment of measles elimination.
Given the likelihood of significant complications in military-age popula-
tions and the possibility of natural or other reservoirs, future DoD vaccina-
tion policies would probably have to take into account possible post-eradi-
cation outbreaks.
Properly administered measles vaccine results in immunity lasting for at
least 16 years (Markowitz and Katz, 1994), but possible security concerns
may require further longitudinal studies evaluating the duration of vaccine-
induced immunity. Even if civilian vaccine practices were curtailed or dis-
continued, it may still be necessary to immunize the military or at least
maintain a stockpile of measles vaccine, which would require planning and
budgeting for an uninterrupted or standby surge production capacity. If the
biowarfare threat from measles were deemed creclible, the efficacy of the
current vaccine might have to be assessed in the context of aerosolized
transmission, which would depend on identifying an appropriate animal
model for human measles. If researchers found that the vaccine were not
entirely protective, research into possible antiviral therapies may be war-
ranted. Surveillance systems would have to be geared to meet a possible
measles threat, and rapid clinical diagnostics and detector technologies may
have to be researched and developed. These are only a few of the possible
issues that may have to be addressed during a security-based review.
Conclusion
Incorporating a national security process into an eradication effort
introduces a dimension not commonly encountered in public health de-
bates. On the one hand, it involves activities that strengthen the objective
and purpose of the eradication effort. On the other hand, it raises concerns
that may be new to public health practitioners. Security reviews may alter
the public health community's fundamental expectations for eradication,
OCR for page 163
THE CHALLENGES TO POST-ERADICATION OUTBREAKS
163
and raise questions about traclitional assumptions concerning disease eradi-
cation. For example, the conventional wisdom associating significant finan-
cial savings with ending routine immunizations may be challenged. Money
saved on immunizations may have to be spent on expanded surveillance
and vaccine stockpiling programs, for example. As America enters the 21st
century, cognizant of the revolutions in biotechnology and genetics and the
prospect of biowarfare, the health and security communities must work
together to ensure both public health and national security. Disease eradi-
cation supports both imperatives, but the long-term consequences must be
anticipated from the outset.
UNDERSTANI)ING THE PUBLIC AND MEDIA
RESPONSE TO AN OUTBREAK
Ann E. Norwood, M.D.
Colonel, U.S. Army Medical Corps
Associate Professor and Associate Chair, Department of Psychiatry
Uniformed Services University of the Health Sciences, Bethesda, MD
A swift, well-coordinated, and effective public health response is the
most powerful psychological intervention in a post-eradication outbreak.
Through their actions and comments, political leaders, public health ex-
perts, and other key figures at the local, state, and federal levels will shape
individual and community expectations, beliefs, and behaviors. In particu-
lar, the management of the outbreak in the first hours to days sets the tone
for societal responses.
Fear and the Public Reaction
Infection by a microorganism taps into very deep-rooted fears of being
invaded and destroyed by an invisible force. The lack of sensory cues asso-
ciated with infection makes it impossible to discern whether or not one has
been infected. Many organisms produce ubiquitous symptoms that can go
undiagnosed until it is too late to save the victim. A delayed onset between
exposure and illness produces tremendous anxiety and uncertainty in those
fearing they have been infected. Moreover, much of the public does not
have the scientific background with which to understand the outbreak.
By definition, post-eradication outbreaks would produce diseases rarely
seen in medical practice. There would be limited medical knowledge about
diagnosis, treatment, and outcome in the general community. This poses
considerable uncertainty for both physicians and patients. In many coun-
OCR for page 164
164
.
ventlons;
CONSIDERATIONS FOR VIRAL DISEASE ERADICATION
tries, an epidemic of a disease that produces a high acute mortality rate will
be a new experience. While people can become accustomed to quite terrible
circumstances, there is a great possibility of panic when they are exposed to
an unfamiliar threat for the first time. For example, the first use of gas and
the introduction of machine guns in war both produced panic in the troops.
As soldiers became familiar with these weapons, however, panic dissipated.
Exposure to the dead and disfigured also produces strong psychological
responses and is a potent psychological stressor.
Understanding which aspects of biological agents invoke terror can aid
in developing intervention strategies. For example, unrealistic beliefs about
microbes and viruses can be addressed through education. Informing people
about what they can expect, thereby lessening surprise and affording them
a sense of control through predictability, can alleviate uncertainty.
Fear-producing aspects of outbreaks include:
the potential for high numbers of casualties;
· a potentially limited availability of treatments;
in some cases, uncertainty about the effectiveness of medical inter-
the possibility of an epidemic involving person-to-person transmis-
sion; and
· dispersion of the ill, which can erode the sense of safety in regions
far from the original source of infection.
Based on data gleaned from studies of disasters and observations of
past outbreaks, there are certain elements of an outbreak that influence the
public's reaction. How an outbreak has arisen has major implications for
behaviors. An act of bioterrorism, for example, can be expected to provoke
widespread rage which can be difficult to manage with respect to
scapegoating. It could also result in ill-advised policy decisions made in the
heat of the moment. Grotesqueness has been demonstrated to be a powerful
predictor of strong emotional responses. Diseases like smallpox and hemor-
rhagic fevers, such as Ebola, evoke terror in many people. The larger the
outbreak, the more strain it places on the community. The disruption of
basic community functions and normal activities adds secondary psycho-
logical and behavioral stressors.
The media will play a major role in determining how the public reacts
following an outbreak. In a climate of uncertainty and fear, the public will
thirst for information to help them gauge their personal risks. Radio, televi-
sion, and the Internet should be used to provide accurate, non-sensational-
ized information in order to control rumors and provide instructions on
personal safety measures.
Psychological responses to outbreaks of eradicated disease can include:
OCR for page 165
THE CHALLENGES TO POST-ERADICATION OUTBREAKS
165
the attribution of somatic symptoms to intoxication and infection,
scapegoating and stigmatization, and social isolation and paranoia, which
contribute to the development of conspiracy theories and mistrust. As the
outbreak continues, people may become demoralized and lose their faith in
the institutions that are supposed to protect them. All of these responses are
influenced by cultural and religious views about causality, cleath, and dy-
ing. Therefore, it is very difficult to generalize findings across cultures and
over time.
The Nature of Panic
The word "panic" is often used to describe psychological responses to
disease outbreaks. Panic refers primarily to a group phenomenon in which
intense, contagious fear causes individuals to think only of themselves.
They become paralyzed by fear or seek to escape by any means necessary.
Panic also refers to an individual response characterized by the loss of
rational thought due to overwhelming terror. A major goal of preparation
and response for a post-eradication outbreak is the prevention of panic and
the preservation of individual, group, and community function.
In examining historical responses to epidemics, Garrett (1994) has made
the following observations:
Panic does not always go hand in hand with epidemics, nor does its scale
correlate with the general gravity of the situation. Indeed, history demon-
strates that population responses to diseases are rarely predictable, open
peculiar.... Where a hefter dose of public concern was warranted, as in
the case of the 1918-19 [influenza] pandemic, an oddly common feature
was nonchalance.... In contrast, public reaction to the 29 deaths in
Philadelphia [Legionnaires' disease] was extraordinary.... Phrases like
"explosive outbreak," "mysterious and terrifying disease," "Legionnaire
killer," and "killer pneumonia" filled press accounts as well as the on-
camera statements of Philadelphians and politicians.
As this statement implies, the way the news is covered shapes the public
response to an outbreak.
Panic is rare following disasters. For example, panic did not occur
following the Tokyo satin attack; although thousands of people sought
medical care after the satin attack, they were orderly and obeyed instruc-
tions, and first responders and hospital staff managed their responsibilities
well. However, this may not happen during an epidemic. The risk factors
tor panic are:
surprise and novelty,
the belief that there is only a small chance of escape,
· seeing oneself as high risk for becoming ill,
OCR for page 166
166
CONSIDERATIONS FOR VIRAL DISEASE ERADICATION
.
available, but limited, resources in which there is a situation of
"first come, first served,"
a perceived lack of effective management of the catastrophe, and
loss of credibility of authorities.
The government and medical community will play large roles in shap-
ing the public's reaction. Medical responses will be scrutinized for efficacy
and fairness. For example, political and medical decisions about what
groups to vaccinate first, or which groups will be given highest priority for
a limited supply of vaccine, may have a chilling effect. These decisions may
also affect those responsible for providing medical care and other essential
community services. For example, a question that frequently arises in the
first responder community is, "In the event of a contagious agent, would
our families be given high priority as well as us?" Policy makers must
address how decisions in this area will be made and explained to the public.
Protocols should be developed for these scenarios in order to mitigate panic
and minimize the risk of poor decisions in the midst of a crisis.
The provision of accurate knowledge is an important determinant in
whether panic will occur. Even if the news is very bad, knowledge is prefer-
able to uncertainty in which fantasies and rumors run rampant. Providing
inaccurate news or lying to the public results in loss of credibility that
cannot be regained, as was seen at Three Mile Island and in Surat, India.
Untrained or mistrained responders can cause group breakdown and
institutional panic, which would not be reassuring to the public if it oc-
curred in a hospital, for example. There are several factors that could
contribute to group disorganization and institutional breakdown:
· distrust prior to the event,
· a breakdown in communication
· failure of critical elements,
poor leadership, and
a perception that there is no effective response.
Realistic simulation training maximizes the probability of people per-
forming their roles well by identifying key personnel and facilitating the
development of personal relationships. It minimizes panic by teaching deci-
sion-making and problem-solving skills under calm conditions, rather than
during the chaotic time of an actual response.
While panic may not be evident during a crisis, there will likely be
significant numbers of the "worried well" seeking medical evaluation. The
signs and symptoms of anxiety are protean and ubiquitous. People who
have been exposed to infection often worry that they are becoming ill when
they experience anxiety symptoms. Following an outbreak, well-designed
OCR for page 167
THE CHALLENGES TO POST-ERADICATION OUTBREAKS
167
risk communication can reassure low-risk citizens that they are not sick,
thereby reducing the number of people seeking hospital evaluation.
Now, despite having devoted so much time to a discussion of the
multidimensional nature of panic, it may be wise to strike the word "panic"
from our lexicons. Telling people not to panic may, in fact, reinforce the
behaviors we are trying to prevent. Also, in terms of trying to understand
and develop predictive models about how the public will behave, it is far
more helpful to explicitly describe the behaviors rather than lumping them
uncler the rubric of "panic."
Historical Examples and Post-Outbreak Interventions
Following the SCUD attacks on Israel during the Gulf War, for every ill
or injured casualty seeking medical assistance, there were four non-ill be-
havioral casualties seeking aid. This phenomenon has also been observed
during disease outbreaks. Furthermore, medical and hospital support per-
sonne! are not immune from fear-organized behaviors, such as absenteeism
and decreased performance, especially in circumstances where emergency
and health personnel are worried about their families.
The 1994 outbreak of pneumonic plague in Surat, India, illustrates
how fear-organized behaviors can dominate the public's response to an
epidemic. This is true despite the fact that, in this case, the organism was
susceptible to antibiotics. Stigma and social isolation had economic as well
as psychological consequences, and fear of disease dissemination eroded
feelings of safety in many parts of the world. Communicating the risks and
managing fear, anger, and paranoia should be major intervention objectives
in the wake of a post-eradication outbreak.
Overdedication- people continuing to work despite suffering the ef-
fects of fatigue from sleep deprivation and intense mental and physical
activity is a common problem in crisis situations. There are scores of case
examples in which exhausted leaders have made poor clecisions which have
endangered others. Protocols need to specify plans for rotating all person-
nel. This is especially critical in situations in which the outbreak may ex-
tend from days to weeks to months.
The tendency of the science community to debate and criticize as a way
of seeking the truth will not reassure the public and may actually lead to the
loss of credibility. A number of experts have emphasized the need for "one
voice" to provide information to the public. While this is a laudable goal, it
may be unreachable given the long-standing traditions of scientific dis-
course. We need a better understanding of how the public should be trained
to anticipate and cope with the diverse, and often conflicting, information
that will be disseminated in the wake of an outbreak. For example, follow-
ing the midwestern U.S. floods in 1997, there were discrepancies in the
OCR for page 168
168
CONSIDERATIONS FOR VIRAL DISEASE ERADICATION
amount of time residents were told to boil their water by different govern-
ment agencies. In the face of this confusion, how did people decide what to
clo? Discrepancies between what leaders and experts are telling people to do
and what they, themselves, are doing, will not escape media notice and will
undermine the credibility of the authorities.
Recommendations
· Multiple research methodologies must be employed to address the
psychological and behavioral consequences of a post-eradication outbreak.
· Policies on the distribution of limited resources, such as vaccine
and antibiotics, should! be informed by behavioral research and ethical
review.
· Planning for the behavioral and psychosocial aftermath of a post-
eradication outbreak requires a multidisciplinary effort involving political,
medical and mental health leaders, governmental and social institutions,
ant! the citizenry.
· While developing outbreak policies, the emotional and physical
impact of a major disease outbreak on leaders must be taken into account
in order to ensure rational. informed decision-makin~ during the crisis.
Research should be directed toward delineating how best to enlist
media support in the management of outbreaks
. . . . . . ~
.
The behavioral and societal effects of past infectious disease out-
breaks should be studied systematically and a taxonomy developed which
can be used to identify the effects and course of responses to outbreaks.
These studies should examine responses in individuals, families, small
groups, hospitals, and communities. The review should! also examine the
response to past uses of mass quarantine, evacuation, immunization, and
isolation. Information gleaned from these studies can serve as the basis for
hypotheses which can be tested in future outbreaks.
· Infectious disease specialists, risk communication experts, public
officials, and members of the media should develop communication and
information programs for each disease of concern. Effective risk communi-
cation after an attack will be key in promoting healthy and constructive
public behaviors and reducing fear-organized behaviors. These programs
should designate who will inform the public, and they should delineate the
specific actions recommended for citizens to minimize their possibility of
falling ill. Messages must be specifically designed for each segment of the
population, based on available information and input from credible com-
munity leaders.
OCR for page 169
THE CHALLENGES TO POST-ERADICATION OUTBREAKS
POST-ERADICATION CHALLENGES
IN THE DEVELOPING WORLD
Ellyn W. Ogden, M.P.H.
169
Worldwide Polio Eradication Coordinator and Senior Technical
Advisor for Health and Child Survival, Bureau for Global Programs
U.S. Agency for International Development, Washington, D.C.
The U.S. Agency for International Development (USAID) provides for-
eign assistance to developing countries and maintains offices and ongoing
programs in nearly every country of the developing world. Immunization
has long been a hallmark of AID's child survival activities. In 1996, at the
urging of Rotary International, Congress directed USAID to establish a
global polio eradication program that would provide a minimum of $25
million per year for polio-specific activities. The rationale for this earmark
was based on the success of the eradication efforts in the Americas, where
USAID had been the largest external donor, and on the belief that savings
would come once vaccination could stop. Annual estimated savings from
vaccination costs alone ranged from $230 million per year in the United
States to $1.5 billion globally, in perpetuity, once immunization ceased.
Because of a complex budget structure and earmarks for USAID, much of
the funding had to come out of existing resources, primarily routine immu-
nization programs. Knowing the enormous challenge of immunizing chil-
dren and establishing certification-standard surveillance in the most diffi-
cult-to-reach areas of Africa and South Asia, often under conflict situations,
as well as concerns regarding cessation of immunization, USAID entered
into this commitment with skepticism. However, once engaged, the com-
mitment has been strong and visible, with hopes that USAID, working
closely with its partner organizations, would leave a long-term legacy
behind.
I have listened carefully to the presentations over the last few days and
the doubts being raised about the feasibility of stopping polio immuniza-
tion. If true, USAID is in a very difficult position. We have pledged to
maintain political, financial, and technical involvement until the world is
certified polio-free, even if the road is bumpier and longer than originally
planned. Any lessening of the effort at this point in the eradication program
would be a signal to other donors and to host country governments that
they can retreat. This risks halting the momentum currently enjoyed by the
program as well as setting the stage for polio cases to resurge to pre-
eradication levels—100 times what they are today. USAID does not want to
send this signal without seriously considering all of the scientific data and
OCR for page 170
170
CONSIDERATIONS FOR VIRAL DISEASE ERADICATION
opinions, how the public and Congress would perceive it, and what it
would mean in terms of USAID's credibility.
While many reputable scientists and virologists are firm in their belief
that polio eradication is feasible and immunization can safely stop at some
point in the near future, others, equally strongly, believe that polio immuni-
zation may never cease. If the funds spent on eradication cannot be re-
coupect, then how do we tell our constituents—the children in developing
countries that we have invested nearly $1.8 billion thus far, anal that this
amount is increasing, for an activity that may never be stopped. In the
meantime, in a district in Zambia, for example, it costs about $11 per
capita to provide an essential package of basic health services, but currently
available resources amount to only $5 per capita. Access by developing
countries to limited supplies of vaccine stockpiles and costs to contain
potential outbreaks in the post-eradication era, raise additional issues of
equity and public health priority.
This is a very serious issue. The need for eradication and anticipating
post-eradication needs must be balanced with the general health needs of
the children, while at the same time maintaining USAID's integrity and
credibility in the eyes of the public, Congress, host countries, and other
stakeho1ders.
There are a number of other important issues that must also be ad-
dressed while considering eradication. Eradication programs have conse-
quences, both opportunities and threats, beyond wiping out a virus. First,
the great need to provide every child with basic preventive health care,
including immunization. House-to-house strategies are no longer enough
for delivering polio vaccine, so USAID and its partners are now going child-
to-child, which requires intensive effort looking for children in places where
we have never looked before. Like the homeless here on the streets in
Washington, D.C., it is easy to simply walk by them. But we cannot do this
in the slums of Calcutta, for example. To achieve polio eradication we must
find and immunize every child. Once we find them how can we ignore them
for other services? How do we bring the same intensity of effort and find
the resources to bring basic preventive services to them as well?
Second, polio eradication is helping to build or revitalize many aspects
of health infrastructure in developing countries. One example is the impor-
tant area of communications. Most laboratories in developing countries did
not have dedicated phone and fax lines until USAID helped pay for them in
their effort to establish an effective laboratory network for acute flaccid
paralysis (AFP) surveillance. With foresight and planning, the laboratory
network will extend beyond AFP, but in order for this to happen, objectives
need to be outlined from the beginning. Even if eradication efforts fail, the
network is a legacy that must continue if we are ever to build a stronger
system of health services. It is this type of global communication system
OCR for page 171
THE CHALLENGES TO POST-ERADICATION OUTBREAKS
171
that will alert us to outbreaks of disease anti enable us to take corrective
action. USAID considers this a good investment for polio eradication and
for protecting the United States.
Finally, convict situations are posing tremendous challenges in many
developing countries. In the Eastern Congo, for example, administering
vaccinations requires negotiating with the Congolese rebels to set aside
certain days of peace- something I have personally done. Despite all good-
faith negotiations, it is impossible to control all factions or undisciplined
soldiers who shoot anybody they see. Everyone from volunteers, to health
workers, to staff of U.N. organizations, to clonors, regularly demonstrate
acts of courage and put themselves at risk in an effort to vaccinate children.
Sometimes, these acts of bravery are a step toward peace-building. Some-
times, vaccinators die while conducting eradication activities. CDC, to their
credit, has established a Heroes Fund for the many vaccinators who have
died since polio eradication started. We should not enter eradication efforts
lightly without thinking of these people who are giving up their lives for the
sake of eradication.
USAID is proud of our involvement in polio eradication and our contri-
bution to reducing the death, disability, and social stigma that accompanies
the disease. The global program can be prouc! of the success so far; thou-
sands of cases of polio have been prevented; children that might have been
paralyzed are walking, will marry, be involved in economic activities, and
be vital members of their communities. USAID leadership to maximize the
benefits of polio eradication, to raise awareness of the health needs of
children, and to seek peace will have provided a great service regardless of
whether immunization can cease or not.
REFERENCES
Alibek K. 1999. Biohazard. New York: Random House.
Bentley J. 2000. Hospital Preparedness, Presentation at the Second National Symposium on
Medical and Public Health Response to Bioterrorism, Washington, D.C., November 28-
29, 2000.
Centers for Disease Control and Prevention. 1992. Public sector vaccination efforts in re-
sponse to the resurgence of measles among preschool-age children—United States-
1989-1991. Morbidity and Mortality Weekly Report 41(29):522-525.
Fidler D. 2000. Legal Issues Surrounding Public Health Emergencies, Presentation at the
Second National Symposium on Medical and Public Health Response to Bioterrorism,
Washington, D.C., November 28-29, 2000.
Garrett L. 1994. Pp. 175-176 in The Coming Plague: Newly Emerging Diseases in a World
Out of Balance. New York: Penguin Books.
Gremillion DH and Crawford GE. 1981. Measles pneumonia in young adults: An analysis of
106 cases. American Journal of Medicine 71:539-542.
OCR for page 172
172
CONSIDERATIONS FOR VIRAL DISEASE ERADICATION
Henderson DA, Inglesby TV, Bartlett JG, Ascher MS, Eitzen E, Jahrling PB, Hauer I, Layton
M, McDade J. Osterholm MT, O'Toole T. Parker G. Perl T. Russell PK, and Tonat K.
1999. Smallpox as a biological weapon: medical and public health management. Journal
of the American Medical Association 281:2127-2137.
Inglesby T. Grossman R. and O'Toole T. 2001. A plague on your city: Observations from
TOPOFF. Clinical Infectious Diseases 32(3):436~45.
LeDuc JW and Becher J. 1999. Current status of smallpox vaccine. Emerging Infectious
Diseases 5:593-594.
Markowitz LE and Katz SL. 1994. Measles vaccine In Plotkin, SA and Mortimer, EA, (eds.)
Vaccines, p. 248. Philadelphia: SUB Saunders.
Osterholm MT and Schwartz J. 2000. Living Terrors. New York: Delacourte Press.
O'Toole T. 2000. Biological Weapons: National Security Threat and Public Health Emer-
gency, CSIS Presentation, Washington, D.C., August 22, 2000, p. 10.
Representative terms from entire chapter:
viral disease
