Pandora Report: 8.12.2016

In the event you find a skunk with an ice cream cup stuck on its head, you can use Ebola PPE like this Southern Ontario paramedic. The yellow fever outbreak is surging and yet again, the WHO is being called out for poor leadership and outbreak response. “An internal draft document sent from WHO’s Africa office to its Geneva headquarters in June cited a lack of senior leadership at WHO. It said the emergency outbreak response manager and team in Angola ‘are unable to lead or positively influence the operational direction and scale of containment efforts.” Science and technology issues truly impact voters, so are 20 questions many science organizations feel Presidential candidates should have to answer.

Medical Countermeasures Dispensing Summit: National Capitol Region
On-site attendance is full, but you can still enjoy the August 16-17 summit virtually. Organized by the U.S. Department of Health and Human Services Assistant Secretary for Preparedness and Response, the regional summit allows people “direct access to local best practices and MCM subject matter experts, as well as to create collaborative environments to address nationally identified target areas and hear directly from stakeholders at all levels of response planning.” The Washington, DC summit will have a dual-track agenda and allow each attendant to base their participation on topics they find most relevant.

Are Exotic Pets a New Biothreat?
Dr. Laura Kahn is making us second guess exotic pets and invasive species in the biodefense paradigm. While not the normal “go-to” when thinking of bioweapons, she notes that a handful of security experts are raising concerns over their ability to impact ecosystems and the agriculture sector. Pointing to a recent paper in Biosafety, Kahn draws attention to the potential biological attack using non-native species to infiltrate, impact natural resources, injure soldiers, transmit disease, etc. While this threat may seem unlikely, the truth is much more startling – we’re already under attack by non-native wild animals via the exotic animal market. “Invasive species—which can take the form of anything from microscopic organisms to plants, fish, and mammals—are those inhabiting a region where they are not native, and where they are causing harm. They displace native species by either eating them or eating their food. In part because they often have no natural predators in their new location, they can disrupt ecosystems, delicate webs of plants and animals that evolved to exist in balanced harmony. This can wreak havoc on environmental, animal, and human health.” A prime example would be Australia in the 18th century, which endured a rabbit invasion by way of European settlers. As a result of these furry invaders, Australia is reported to lose more than $87 USD per year. Delicate ecosystems and dangerous animals have a role in this compounding threat and it’s not just related to the illegal trade of animals. Dr. Khan notes that the legal importation of animals is a substantial source for risk – between 2005 and 2008, the U.S. imported more than one billion live animals. The regulatory agencies involved in oversight of these processes are spread across the Department of Agriculture’s Animal and Plant Health Inspection Service, the Department of the Interior’s Fish and Wildlife Service, the Department of Health and Human Services’ Centers for Disease Control and Prevention (CDC), and the Department of Homeland Security’s Customs and Border Protection. Aside from the obvious challenges of legal importation, wildlife trafficking still occurs and when coupled with the exotic pet market, the volume of threats is far greater than we might consider. “It appears that exotic pets fall through the regulatory cracks much to the peril of our nation’s ecosystems and agriculture. In fact, they should be considered potential biological threats, and the regulation loopholes allowing their unfettered importation should be closed.”

Colistin-Resistance, Where Is It Now?
The Olympics may have taken over Brazil, but colistin-resistant bacteria are the latest arrival in the South American country. Making its debut, the MCR-1 gene that allows bacteria like E. coli to become resistant to the antibiotic of last resort (colistin), was found in the infected foot wound of a diabetic patient. “In earlier research, these investigators showed that E. coli harboring the mcr-1 gene had been present in food-producing livestock in Brazil since at least 2012. ‘In spite of this, we had previously recovered no isolates from humans that were positive for mcr-1,’ said coauthor Nilton Lincopan, PhD, Assistant Professor in the Department of Microbiology, Institute of Biomedical Sciences, Universidade de São Paulo, Brazil.” This news comes at an especially relevant time as the concerns over water quality and aquatic events are being voiced daily. The growing reports of MCR-1 genes are pushing for more global surveillance on antibiotic resistance. In the U.S., Minnesota is making strides to combat the rise of antibiotic resistance. Utilizing a One Health approach to antibiotic stewardship, their 5-year plan will incorporate “Minnesota’s departments of health and agriculture, along with the Board of Animal Health and the Minnesota Pollution Control Agency (MPCA), to work together to promote the judicious use of antibiotics in humans and animals and get a better sense of how antibiotic use is affecting environmental health.”

Aerosol Stability of Ebola Strains
Do you ever find yourself pondering the aerosol transmission capability of certain Ebola strains? Researchers are doing just that in the latest Journal of Infectious Diseases. During the 2014/2015 outbreak, there was a lot of concern over the potential for aerosol transmission, especially in the healthcare environment (invasive procedures, suctioning, etc.). Despite there being little epidemiological evidence to support this transmission route, there were substantial reports and media speculation to push researchers to go back to the drawing board regarding Ebola transmission. Looking at two Ebola strains (1976 and 2014 strains), researchers found that there was “no difference in virus stability between the 2 strains and that viable virus can be recovered from an aerosol 180 minutes after it is generated.”

The Latest on Zika
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The U.S. Department of Health and Human Services has awarded $4.1 million to Hologic, Inc. for the advancement of a Zika blood screening test. To aid in the fight against the growing outbreak, federal employees are deploying to help stop the outbreak. With Congress and the White House at an impasse, hundreds of employees from DHHS, the Defense Department, and the State Department are all deploying to help combat the outbreak. Florida has reported more infections, bringing their total local transmission cases to 25, while a Texas newborn has died from Zika complications. Texas has reported 99 cases, including two infants. You can read about the investigations into the local transmission cases hereUSAID has announced their investment of over $15 million to accelerate development and deployment of 21 innovations to combat Zika. “The award nominees range from deployment of mosquitoes infected with Wolbachia, a naturally-occurring bacteria that prevents the spread of disease to humans; to low-cost, insecticide-treated sandals; to a cell phone app that measures wing-beat frequency to not only distinguish different types of mosquitoes but potentially identify whether they are carrying disease.” In a letter to Congress, DHHS Secretary Sylvia Burwell pointed to the lack of federal support, resulting in $81 million having to be transferred to Zika from other programs. As of August 10th, the CDC has reported 1,962 cases of Zika in the U.S.

Stories You May Have Missed:

  • Impaired Growth & Campylobacter Infections – a recent study reviewed the impact of Campylobacter infections in children in eight low-resource settings. Addressing the role of enteropathogen infections on enteric dysfunction and impaired growth in children, researchers performed a multi-site cohort to look at Campylobacter infections in the first two years of life. Following their analysis, they found a high prevalence of the infection within the first year and that a high burden of Campylobacter was associated with a lower length-for-age Z (LAZ) score. Campylobacter infections were also found to bear an “association with increased intestinal permeability and intestinal and systemic inflammation.”
  • High School Student Awarded For Work on Ebola Proteins in Bats-While many of us were attending sporting events or getting into trouble with friends, Rachel Neff was contacting pathology professors and working on a project that would later translate to several awards. Neff’s project focuses “on a protein called VP35 that is found in both the Ebola virus and the bat genome. The Ebola version of VP35 suppresses the immune response in infected animals, allowing the virus to multiply. Bats are thought to carry the Ebola virus — and transmit it to humans — but are not sickened by it themselves. Scientists are exploring whether VP35 in bats may interfere with Ebola VP35, protecting the bats from disease.”

 

Pandora Report: 7.29.2016

Happy Friday! With the Olympics right around the corner, there’s a lot of buzz surrounding the games (not just Aedes mosquitoes) and the athlete living quarters. Make sure to watch the PBS special, “Spillover- Zika, Ebola & Beyond“, on August 3rd at 10/9c. The special will look at the rise of spillover diseases like Nipah and the impact of human behavior on the spread of zoonotic diseases. The Society for Healthcare Epidemiology of America (SHEA) reported a new study that finds three key factors increase the risk for patient-to-patient transmission of the extremely resistant CP-CRE. The Democratic National Convention closed last night and Hilary Clinton made it a point to say, “I believe in science”, which highlights  the stark differences between the candidates on topics like climate change and stem cell research. 

What Damage Could CRISPR Do To The BWC?
Daniel Gerstein points to the approaching Eighth Review Conference of the Biological Weapons Convention and the assessment of new technologies, like CRISPR. Since James R. Clapper, Director of National Intelligence, stated that genome editing is a global danger, many are waiting to see what the convention will say about the future threats of technologies like CRISPR. Gerstein notes that, “if the seven previous review conferences are any indication, the gathering in November will recognize Crispr’s contribution to the biotech field, then enthusiastically declare the convention fit to address any problems it might create. But will that be enough?” The flexible nature of the convention is meant to support the ever-changing world of science and technology, however this also means that any potential bans on experiments are that much more challenging. In his article, Gerstein discusses the assessment of CRISPR as a nonproliferation threat and the risks associated with limiting technological innovation. Despite the challenges of banning certain biotechnologies, there are things that can still be done within the conference. Surveillance and training are imperative, especially in terms of “spotting the development of new pathogens or the modification of existing ones”, and national responsibility needs to be part of this equation. Gerstein’s points on not just national implementation, but also national responsibility emphasizes the transition from a traditional method into an emphasis on people and activities. Practices need to match the pace of biotech development, which means expanding the Implementation Support Unit, strengthening surveillance capabilities, and reinforcing institutional structures. “Those gathering at the review conference in November must seriously consider whether advances in biotechnology have made the existing bioweapons convention obsolete, but they must also ask what more the convention can do, as the reigning body for regulating biological weapons, to ensure that new biotechnologies continue to be used for peaceful purposes only.”

Half of Americans Say Infectious Disease Threats Are Growing  

Courtesy of Pew Research Center
Courtesy of Pew Research Center

The Pew Research Center conducted a recent survey in the wake of the very public Zika virus outbreak. While some may have noted that Americans aren’t as worried about Zika, the survey found that 51% of U.S. adults feel that, compared to 20 years ago, there are more infectious diseases threats to health today. 82% of Americans polled stated that they pay at least some attention to the news regarding infectious disease outbreaks and 58% believe that Zika is a major threat to the health of women who are pregnant. 31% believe that Zika is a major threat to the U.S. population as a whole, while 58% felt it was a minor threat. The poll also found that more people had heard of Ebola at the time of the 2014 outbreak than Zika as a problem right now. Broken down by demographics, those most worried about Zika include older adults, especially women.

Containment: Lessons Learned and Cringe-Worthy Moments2015_0326_Biohazard_Suits
Tuesday nights won’t be the same since Containment ended – what will we do without the asymptomatic super-spreaders like Thomas, the overly gory hemorrhaging, or the suspension of infection prevention practices? Like any science-based show, there are moments of accuracy and moments of pure dramatic exaggeration. Check out our list of the things we enjoyed about the show and some of the more eye-rolling moments. While it’s rare to have a prime-time show involving an outbreak, we’re hoping that the future will hold more scientifically accurate series that will dismantle the hysteria we too often see during public health emergencies.

Australia Utilizes Bioterrorism Algorithm to Predict Flu Outbreaks
Victoria’s health department is currently using a tool, EpiDefend, that can “accurately predict flu outbreaks up to eight weeks in advance.” Combining environmental data, lab results, and more, the tool is funded by the US Department of Defense and designed by the Australian Department of Science and Technology (DST) to aid in Australian disease prediction practices and strengthen global bio-surveillance. ”Our team’s goal is dual-purpose, we want to fulfil our defence charter, protecting our forces against intentionally released biological agents; but disease forecasting will also support the national security and public health areas,” said Tony Lau, defence scientist. EpiDefend incorporates electronic health records (EHR) via the healthcare sector, which means it can be especially powerful, but also requires the presence and reliability of EHR. The system uses an algorithm that is still being refined. “Particle filtering is a technique which helps us close in on the degree of uncertainty by the help of information gathered from particular situation. In other words, it helps the algorithm churn out more precise readings.”

Zika Virus
The Department of Health and Human Services (HHS) has published a webpage on what you need to know about Zika virus. A recent study is estimating that as many as 1.65 million women in Latin American could be infected while pregnant. Researchers, from another study published in the Annals of Internal Medicine, are pointing to a low risk for international Zika spread from the 2016 Olympics in Brazil.  Researchers calculated “the worst-case estimates of travel-associated Zika virus by assuming visitors encounter the same infections exposures as local residents. This is highly unlikely, as visitors would be staying in screened and air-conditioned accommodations, as well as taking personal preventive measures. But under the authors’ pessimistic conditions, they estimate an individual traveler’s probability to acquire infection in Rio de Janeiro is quite low. Specifically, they estimate anywhere from 6 to 80 total infections with between and one and 16 of those infected experiencing any symptoms.” Florida officials announced the investigation of another two potential cases of local-transmission. These new cases have pushed the FDA to curb blood collection in Florida. A new study performed a real-time Zika risk assessment in the U.S, suggesting that 21 Texas counties along the Texas-Mexico border, the Houston Metro area, and throughout the I-35 corridor (San Antonio to Waco) have the greatest risk for sustained transmission. As of July 27th, the CDC has reported 1,658 cases of Zika in the U.S. 

Stories You May Have Missed: 

  • CSIS Curated Conversations on Pandemic Preparedness & the World Bank – The Center for Strategic & International Studies has made its Curated Conversations podcast available on iTunes, which means you can check out the June 3rd episode, “the World Bank President on Preventing the Next Pandemic”. The World Bank Group president, Jim long Kim, discusses funding to help prevent the next pandemic and lessons learned from Ebola.
  • Joint West Africa Biopreparedness Efforts – The DOD is investing in the Joint West Africa Research Group to help improve and sustain biopreparedness within the region. Following the Ebola outbreak, this new program will build upon existing programs and strengthen lab and clinical resources, as well as biosurveillance efforts.
  • Yellow Fever in the Americas? The Pan American Health Organization is currently investigating a case of yellow fever in a man who traveled to Angola. Genetic testing is underway, but there is concern that the virus could ramp up in the Americas during a vaccine shortage.

Ebola 2014: The Infection Preventionist Perspective

By Saskia Popescu

Unlike many infectious diseases, especially ones with a relatively small number of occurrences, the Ebola outbreak that started in 2014 received a sensational amount of attention. While many in public health keep tabs on outbreaks (thanks ProMed!), it’s not uncommon for the rest of society to remain blissfully unaware unless the bug comes knocking on their front door. I’ve been captivated with Ebola (now called Ebola Virus Disease, or EVD) since a young age after Richard Preston’s sensational book, The Hot Zone got passed to me during a family vacation. The first whispers and later emails of the surging cases in West Africa were pretty astounding in early 2014. Usually these outbreaks occur in small blips and then die off a few weeks or months later. I was working in Infection Prevention & Control at a pediatric hospital at the time and, like many, didn’t think too much about the outbreak pertaining to the US and even if it did, our infection control practices should be able to handle an organism that required Contact/Droplet isolation. I put some updates in our monthly newsletter and continued to watch as West Africa became overwhelmed with EVD.

Like many public health issues, no one really starts hitting the panic button until a disease shows up and you’re scrambling (and trust me, most of the time, you find out retrospectively) to do damage control. The IP (infection prevention) world started to get worried in late July when Emory University Hospital accepted and began treatment the first two EVD patients transported into the US from their field assignments in West Africa. Questions about isolation and practices were asked, but again, no one really worried too much since these patients were flown directly to Emory due to their special infectious disease isolation unit. Suddenly, on September 30th, 2014 a media storm announced that a patient being treated at Texas Health Presbyterian Hospital in Dallas, Texas, was positive for EVD. I can personally tell you, this is when the proverbial crap hit the fan for just about every healthcare facility and IP in the US. A visiting your emergency department, being sent home, and then coming back with a highly infectious disease that few physicians know well enough to suspect, let alone diagnose or treat, is pretty much the equivalent of an IP nightmare. So what could we do?

First, I should say that every hospital with an IP team (most of them have at least one IP) experienced a massive level of panic, anxiety, and stress dedicated to avoiding this, so please, give them a pat on the back. I am fortunate that my IP team consists of not only enthusiastic, ridiculously talented and intelligent people, but they know how to respond to crisis in the flip of a switch. We quickly pulled together a committee to encompass all people that would play a role in the preparedness and response of an EVD patient. Fortunately, by this time, Emory had released an extremely helpful document that discussed their experiences and lessons learned. We met our committee (now filled with people from environmental services, facilities, nursing, medical staff, infectious disease, emergency preparedness, the emergency department, and many others) with this document and everything else the Centers for Disease Control and Prevention (CDC) had on EVD response. For many, the difficulty laid in where do we put this patient, what designated staff will care for them, and what will we do with the waste? You pretty much need to have a specific process for both your emergency department if there is a suspected case, but also a designated wing you can move patients out of and move this potential EVD patient into. Without going too much into detail, one of the trickier components became the PPE (personal protective equipment) and waste process of a potential patient. CDC PPE recommendations were changing almost daily (or at least that’s how it felt). Information was changing so rapidly it was a constant cycle of checking their website, talking with peers, and attempting to update instructional handouts and training tools for staff incase we happened to get a potential patient. Historically, EVD PPE recommendations came from outbreaks in Africa with little access to the equipment and capabilities we’re used to in the US. The ability to intubate a patient or insert a central line opened up a Pandora’s box of potential transmission scenarios, leading to difficulty in establishing a solid PPE process. Acquiring the PPE was another struggle. Our materials management team worked tirelessly to find the ever changing products we would need to not only have PPE kits in our emergency department and urgent cares, but also to sustain care for a patient for several days. The sustainability was a huge concern as staff were changing in and out of PPE every 45 minutes due to heat exhaustion and CO2 build-up from the N-95 masks. Once we were able to obtain the PPE, and this was a constantly changing cycle to follow CDC recommendations, training went into effect. One of the greatest struggles was training enough staff to have a proficient understanding of an extremely complex (and dangerous) process. The unique part about EVD PPE practices is that you utilize a buddy system with a checklist – something healthcare workers are not used to and something we had to remind them of (don’t try and memorize this)! We did several drills involving patients projecting a mixture of chocolate syrup and glitterbug to not only prepare healthcare staff, but also show their cross contamination when doffing the PPE.

Courtesy of USA Today
Courtesy of USA Today

The PPE struggles were one small piece of this EVD pie. Many IP’s could probably write a novel about the struggles and random problems that came up during this time. Our ridiculously long days were filled with preparedness meetings, educational trainings, hospital-wide communication, worried calls from people and staff (the comical relief of people calling to ask for an EVD vaccine but refusing to get their flu shot showcases the ridiculousness of what we experienced), educating physicians on signs and symptoms, identifying routes for patient transportation, and coordinating surveillance mechanisms like electronic mandatory travel history (from the affected countries) questions and alerts in the intake process of patients from the emergency department or urgent cares. The simple truth is that the US became so panicked and so obsessed with a disease no one really worried about a few months before, the amount of preparedness that was initiated simply couldn’t be maintained for an extended period of time. Emergency departments and hospitals are comprised of some of the most hardworking and intelligent people you’ll ever meet, but I can honestly say, something like what happened in Dallas could’ve happened in any hospital. Healthcare is an imperfect system and while we struggle to make it better and more robust, it always comes down to overworked staff and communication gaps. My experiences as an IP during the EVD 2014 outbreak, while exhausting, were truly eye opening to the ability of our healthcare infrastructure to respond to such an event. It revealed a lot of gaps in our practices and the state of our preparedness, but overall, it highlighted the growing need for better disease surveillance, preparedness, and attention to biosecurity.