Considerations for Viral Disease Eradication Lessons Learned and Future Strategies: Workshop Summary (2002) / Chapter Skim
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6 The Challenges to Post-Eradication Outbreaks
6 The Challenges to Post-Eradication Outbreaks
Pages 141-172
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From page 141... ...
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 implica141
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From page 142... ...
Preparing for unexpected disease outbreaks also requires a flexible and adaptive post-eradication vaccine program involving continued vaccine production, 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 vaccines)
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From page 143... ...
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 effectively 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)
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From page 144... ...
. In San Antonio, the city's Emergency Medical Services physiciandirector was quoted in a New York Times article by C
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From page 145... ...
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.
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From page 146... ...
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 patients with encephalitis had already been admitted to other NYC hospitals.
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From page 147... ...
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 management, 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.
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From page 148... ...
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 emergency; for example, some may be used solely for quarantine, others for triage, and still others for specialized treatment.
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From page 149... ...
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
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From page 150... ...
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 watchfulness, rumors of disease and case and outbreak investigations will continue, and vaccine must be available in the event of re-emergence.
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From page 151... ...
There was a high degree of confidence that vaccine reserves (approximately 200 million doses deposited at WHO) were adequate for any contingency and vaccine manufacture could be reinstated if necessary.
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From page 152... ...
Although some headway was made over the following t~veIve years and three small clinical trials conducted, the military program did not advance beyond pilot lot manufacture and investigational status, and it did not address the larger public health concerns. Bioterrorism and Vaccine Reserves These events emphasize how the changing landscape following disease eradication affects vaccine policies.
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From page 153... ...
While these examples may not offer exact models, they provide some basis for estimating the potential impact of outbreaks in the post-eradication era and thus, an appropriate size of a vaccine reserve. Rationale for Continued Manufacture, Research, and Development In retrospect, the decision to terminate smallpox vaccine manufacture, research, and development at the time of disease eradication and, instead, rely on existing stocks of vaccine to meet emergent contingencies was fallacious.
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From page 154... ...
This would require that master and working seed viruses be periodically tested under a formal stability program, and that the volume and number of containers of working seed are adequate to meet contingencies for scaled-up production. Since bulk can be stored for longer periods than final containers, a large supply of bulk vaccine should be kept frozen and ready for filling and finishing, although the filled vaccine stockpile must be sufficient to meet emergency requirements.
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From page 155... ...
For example, polio and measles vaccine bulks can be stored frozen for ten years, whereas final filled containers of measles and inactivated polio vaccines have shelf lives of two and three years, respectively. Real-time stability studies are necessary to establish expiration dating and would need to be repeater!
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From page 156... ...
Vaccine liability After disease elimination, the vaccine status under the National Vaccine Injury Compensation Program would change, since the program currently applies only to routine pediatric vaccines. In the case of smallpox vaccine, which was never covered by the program, the manufacturer (Acambis, Inc.)
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From page 157... ...
However, the long-term implications of such efforts, including the possibility of natural or deliberate post-eradication outbreaks, may have security as well as public health consequences. The possible security implications of disease eradication should be assessed at the outset.
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From page 158... ...
Central to this assessment is consideration of a possible natural or deliberate post-eradication outbreak. Eradication is a public health and medical responsibility, but assessing the possible security implications is a multidisciplinary process involving several non-health participants including intelligence, arms control, law enforcement, and defense communities whose roles would be distinct from but supportive of the actual eradication process.
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From page 159... ...
Intelligence and arms control issues should be considered and addressed appropriately. The intelligence community has the ability to collect and assess information that can help determine whether the disease agent in question has biowarfare potential or has been researched or developed as
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From page 160... ...
Similarly, several overseas military laboratories offer regional laboratory expertise that can, and has, supported eradication efforts. The DoD is responsible for assessing the potential impact of eradication campaigns on the future health and operational effectiveness of U.S.
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From page 161... ...
Measles is an infectious disease agent that offers a realistic target for future eradication: humans are the only natural host for wild-type measles virus; an effective measles vaccine is available; following immunization, immunity to natural infection is long-livecl; accurate diagnostic tests are available; and recent regional efforts have demonstrated success in interrupting measles transmission in the United States and Western Hemisphere. Should a concerted effort be initiated to achieve global eradication, a first step in assessing the possible security implications would be to assess
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From page 162... ...
, but possible security concerns may require further longitudinal studies evaluating the duration of vaccineinduced immunity. Even if civilian vaccine practices were curtailed or discontinued, 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.
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From page 163... ...
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.
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From page 164... ...
Radio, television, and the Internet should be used to provide accurate, non-sensationalized information in order to control rumors and provide instructions on personal safety measures. Psychological responses to outbreaks of eradicated disease can include:
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From page 165... ...
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.
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From page 166... ...
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.
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From page 167... ...
This phenomenon has also been observed during disease outbreaks. Furthermore, medical and hospital support personne!
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From page 168... ...
~ . The behavioral and societal effects of past infectious disease outbreaks should be studied systematically and a taxonomy developed which can be used to identify the effects and course of responses to outbreaks.
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From page 169... ...
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.
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From page 170... ...
Second, polio eradication is helping to build or revitalize many aspects of health infrastructure in developing countries. One example is the important area of communications.
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From page 171... ...
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 contribution to reducing the death, disability, and social stigma that accompanies the disease.
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From page 172... ...
Clinical Infectious Diseases 32(3)
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Key Terms
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