Ebola mapping accomplished

  The completion of genomic mapping of the Ebola virus shows that the epidemic originated from a faith healer in Guinea who attracted Ebola cases from all over the region.  When the faith healer died of Ebola, she attracted man followers to her funeral which triggered the spread all over the region, as now-infected mourners returned to their homes. 
  The genomic map was uploaded to the internet so more scientists would have immediate access to it and pharma companies checked to see how the new information might reveal markers indicating their drug was effective. 
  The discovery that the Ebola virus has mutated 300 times since the first case is troubling since this is fast and suggests it is "learning" to adapt and evolve to improve its infectiousness.

Air travel suspended to Ebola-affected Regions and the IHR

   Airlines British Airways, Emirates Airlines, Arik Air, ASKY Airlines, Cameroon Airline, Korean Air and Kenya Airways have all suspected flights to Liberia, Guinea and Sierra Leone.
  The International Olympic Committee has barred athletes from Ebola-affected countries from competing in the Youth Olympic Games which opened on Saturday, Aug 23, in China.  WHO believes that screening that has been implemented in Liberia, Guinea and Sierra Leone is sufficient to protect air travelers.  However, the IOC may be facing many other countries which might opt to stay away, if the IOC did not take this precautionary measure of excluding athletes who might bring Ebola to the games.

    The IHR International Emergency Committee on the West African Ebola epidemic met on Aug 6, 2014 and issued recommendations including this one:   "There should be no general ban on international travel or trade; . . ." 

Despite their recommendation, there is a growing number of states barring trade and travel with Sierra Leone, Guinea and Liberia. This WHO recommendation is consistent with the IHR (2005) overall purpose which reads:

Art. 2. Purpose and scope. "The purpose and scope of these regulations are to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade."

By all accounts, the Ebola epidemic still has months to run its course in West Africa and whether the economic impact can be lessened seems to be increasingly unlikely.

Do Ebola quarantines make good neighbors?

    It's not even a mixed metaphor, but do quarantines, like fences, help or hurt? Diplomatic relationships between the nations of West Africa are being tested in the worst ebola epidemic ever, exceeding the previous largest outbreak in Uganda in 2000-2001 by almost 600% , as of Aug 22, with more than 2,615 human cases as reported by CDC, plagues the region. (Plague has become such a common colloquial verb that we forget the frightening origins of the term-- disease and epidemic.)
    The International Health Regulations (2005), implemented in 2007, have an objective to avoid hurting nations already under pressure from serious outbreaks of contagious diseases, in addition to protecting global health.  Avoiding travel restrictions and trade embargoes against countries reporting these outbreaks are part of the recommendations that are designed to keep the world from unnecessarily impoverishing and crippling the economies of countries particularly in need of response and recovery from a disease outbreak.
  Consistent with the International Health Regulations (2005) the World Health Organization has cautioned countries NOT to impose sweeping bans on travel and trade.  World Bank officials have already predicted a drop from 4.5 to 3.5 percent as the estimate for economic growth in Guinea this year.
  Quarantines, called "unified sectors", established in these countries are considered to be largely ineffective due to their vast size and the inability to control what goes on inside these areas.  Further, food and water are not going into these areas and supplies will soon run out.  There is no law enforcement and there is little to no medical care inside these areas.  The people in this unified area of Liberia are shown in a stand-off with police trying to enforce the quarantine in this photo from The New York Times, Aug. 21, 2014.  WHO recommendations are not being followed, but the Liberian President expressed her reasons why when she said that she took these extreme measures because no one listening to the public health instructions and advice. 
   When it comes to local politics, the Presidents of these nations will have to act in accordance with the fears and pressures of their constituents to keep order, and that may be in contradistinction to any advice they receive from the global community.  That is the reality.  In the end, quarantines may make better neighbors than showing no control efforts at all.

   
   Here is a map produced by CDC, Aug 14, showing the closed borders of West Africa and the intensity of the number of human cases.

Ebola is not caused by witchcraft

A radio message about Ebola is being used in ten different indigenous languages in West Africa to help reduce misinformation about diagnosis and treatment:

'The Ebola virus lives in the bats and does not make them sick. The Ebola virus is released from the bats from time to time and can infect monkeys, chimpanzees, and humans, and other wild animals.

So, can Ebola be caused by witchcraft or a curse, or any other cause? No. Remember: the Ebola virus lives in bats.

And remember: with the right information, and together with our health care workers, we can protect ourselves from Ebola."

This is not as strange as it seems, because Guinea, Liberia, Sierra Leone, Cote D'Ivoire and Nigeria all have social beliefs about the use of witchcraft to harm others, and some have laws to prevent the harm to people stigmatized and harmed by the belief that they are witches or caused harm through witchcraft.  Ghana, on the eastern border of Cote d'Ivoire, for example, has witch and wizard camps for women and men, respectively, and these people never return to their villages and if they do, they are often killed.  Nigeria has anti-witchcraft laws, which criminalize particular crimes against people stigmatized and harmed because they are believed to be witches or caused someone's illness or death.  This is no small problem in West Africa.

Other radio messages warn listeners that if they are sick it is probably malaria and not Ebola, another spot cautions that if there is no fever, there is no Ebola.

Public risk communication is critical in a public health emergency and even in the United States, despite the Executive Order which identifies the Secretary of HHS as the official source of public health information in a public health emergency, it is very likely that the federalism lack of clarity will have any state initiating their own public health information which will lead to a mix of information.  This lack of clarity in where government leadership and authority lies in a public health emergency will lead to problems in our own sophisticated western approach to risk communication and it should be clarified and practiced.

Registered pesticides that become chemical weapons--a rose by any other name is still a rose

    I am going to shift focus from biological threats to the Chemical Weapons Convention and the prohibition against the use of chemical weapons in warfare, because of a recent tragedy.  The dual use of many useful chemicals makes the CWC much less effective in preventing fatalities than it might be. On Aug 9, 2014 two more needless deaths were caused by aluminum phosphide, a precursor to a chemical weapon.
     The recent deaths of two children in Dubai due to the use of a chemical used as a precursor in chemical warfare -- aluminum phosphide -- was not due to maliciousness but due to gross negligence.  It is used as an agricultural fumigant and not intended to be used as a pesticide. When it comes in contact with moisture or dropped in water, it produces phosphine, a gas that was related to phosgene a primary chemical weapon in World War I. It is illegal to use in Dubai but the underground pesticide market is still a threat. It is also a problem in developing countries like India.  But if you think this happens only outside of the U.S., think again. In 2010, two young girls in Utah were also killed in an application of aluminum phosphate at or in their home.  Illegal use of pesticides by unregistered or grossly negligence applicators can still occur.
    The efforts to regulate this pesticide by EPA have led to limiting the use of this chemical to fumigating for agricultural uses, only, and not for home pesticide use. In 2000, the U.S. EPA signed an MOA (Memorandum of Agreement) with pesticide registrants to amend its registration to put more restrictions on the use and labeling of the product. The FIFRA statute considers economics as part of the balance of risk management in deciding on registrations. Notice of importation of a pesticide is required by FIFRA and in Nov 2011 EPA took enforcement action against an illegal importation of 25 tons of pesticide including 50,000 pounds of aluminum phosphide from China.
    This chemical can still be used for residents killing of rodents in burrows and some of the risk extends to and beyond the area in use to the neighborhood.  Aluminum phosphide is identified as a risk among chemicals in Houston.  The Department of Homeland Security lists aluminum phosphide in a sabotage/contamination category of "Chemicals of Interest" but stops short of listing it as a CWC precursor.  Because it is regulated under FIFRA, it can escape the CWC list of prohibited chemical weapons, like chlorine for swimming pools, but it is nonetheless, a deadly chemical weapon.
    I believe that FIFRA works and to take into account the usefulness of aluminum phosphide as a fumigant to protect billions of people from rodents eating the same grain we eat is going to prevent a illness and deaths.  Unfortunately, situations like this should call for more urgency to fund research to find better substitutes for aluminum phosphide. But have we made the administrative process for registering pesticides so difficult that we are willing to accept these needless deaths, in exchange for the uncertainties in testing a new or better substitute?  Incentives are needed to replace these pesticides with safer ones, and modeling toxicological risks could speed up the registration process without increasing the risks to the public. It is time to revisit FIFRA.

In case you were wondering....

     In my July 24, 2014 post, I told you that despite wearing my nano-fiber-infused insect-repellant clothing, once it was removed I was bitten by a mosquito in Dominica in the Eastern Caribbean. In my May 31, 2014 post, you saw that Chikingunya virus had appeared in the Caribbean and the number of infected people was growing.
   In case you were wondering....I survived without contracting any mosquito-borne illness, at least any acute ones.  I had a ten day flu-like illness which was a little disconcerting, but nothing extraordinary, and I probably got it by drying out my throat and becoming susceptible to viruses of all kinds, caused by sleeping in front of a blowing air conditioner unit on my overnight in San Juan, returning from Dominica.
   Chikingunya is not on the regulatory list of diseases that are required to be reported by states. Since it is not a nationally reportable illness (but can be reported to ARBOnet).  Because of the distribution of  constitutional federalism, public health laws and information is in the jurisdiction of the states, and the federal government (i.e., CDC) is not empowered to require that states report any illness not adopted by regulatory processes.  In fact, the list of diseases that states are required to report is fairly short. April 23, 2003 was the last update to the reportable disease list:

Ex. Ord. No. 13295. Revised List of Quarantinable Communicable Diseases

Ex. Ord. No. 13295, Apr. 4, 2003, 68 F.R. 17255, as amended by Ex. Ord. No. 13375, §1, Apr. 1, 2005, 70 F.R. 17299, provided:

By the authority vested in me as President by the Constitution and the laws of the United States of America, including section 361(b) of the Public Health Service Act (42 U.S.C. 264(b)), it is hereby ordered as follows:

Section 1. Based upon the recommendation of the Secretary of Health and Human Services (the “Secretary”), in consultation with the Surgeon General, and for the purpose of specifying certain communicable diseases for regulations providing for the apprehension, detention, or conditional release of individuals to prevent the introduction, transmission, or spread of suspected communicable diseases, the following communicable diseases are hereby specified pursuant to section 361(b) of the Public Health Service Act:

(a) Cholera; Diphtheria; infectious Tuberculosis; Plague; Smallpox; Yellow Fever; and Viral Hemorrhagic Fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named).

(b) Severe Acute Respiratory Syndrome (SARS), which is a disease associated with fever and signs and symptoms of pneumonia or other respiratory illness, is transmitted from person to person predominantly by the aerosolized or droplet route, and, if spread in the population, would have severe public health consequences.

(c) Influenza caused by novel or reemergent influenza viruses that are causing, or have the potential to cause, a pandemic.

    Even though CDC is constrained with what it can require states to report and is limited to this list, they have created a great "work around" that does not violate the federalism principle or the law, giving states jurisdiction over public health matters. CDC developed a relationship with a non-government organization, the Council of State and Territorial Epidemiologists (CSTE) to develop common case definitions to allow reporting through this channel. Some strict-federalists may see this as having the effect of taking power from the states in public health matters, but no one has ever challenged this relationship or process.  It is often the best source of data of illnesses and surveillance of illnesses in the U.S. and makes up the backbone of the National Notifiable Diseases Surveillance System (NNDSS).

    Now, since it is now clear why the data reported by CDC is not from CDC --- take a look at the map CDC published on Aug. 19th. The map created below is based on ARBOnet data, used by CDC to report as of Aug 19, 2014, the number of people infected with Chikingunya.  The states with these reports are in medium blue on the map. These were cases acquired by travelers coming back from traveling to infected areas. Florida is the only state with cases of transmission WITHIN the state, and is particularly of concern since it is spreading so rapidly. We may yet see more states with local transmission.
 

When Ebola Met Hollywood

Craig Schneider at the Atlanta Journal-Constitution contacted me last week regarding his story about how culture had been impacted by ebola and other biological scares. This, of course, was in response to bringing two victims of ebola to Atlanta for treatment. The concern among residents in Atlanta was evidenced in many comments to the articles, Craig told me. I had the opportunity to talk about my new book, The Things That Keep Us Up At Night, the human fear response and the movies that use that fear as a plot device.  Here's the article When Ebola Met Hollywood.  They used quite a bit from my book including the reference to The Satan Bug, a 1965 movie about a laboratory accident with a bioweapon.  (I asked him why they used the movie since it wasn't about ebola and he said they liked the title!) That said, I also told him which movies used ebola (see Chap 8) as the bioweapon or disease, and since he didn't use it, I will list them here, as described in the movie, for my blog readers:

Contagion (US, 2002) "Level Four Ebola Virus"
Global Effect (US, 2002) particularly virulent ebola virus
Azaan (Bollywood, 2011) Ebola variant, bioweapon