The role and significant importance of on-going and robust global medical intelligence and public health bio surveillance and preparedness activities cannot be overemphasized. These efforts are absolutely vital in addressing real or potential epidemiological emergencies, such as the evolving MERS situation. These activities hold great importance for both civilian populations and warfighters engaged in conflicts in areas of the world, or with the possibility of future engagements in warfare, conflict resolution, contingency operations, peacekeeping operations or complex humanitarian missions.
As infectious diseases do not recognize border limitations, international cooperation and outreach is critical and must be a joint and coordinated effort by the public health infrastructure of nations, normally coordinated by the World Health Organization (WHO), and interfacing with various national public health entities such as the U.S. Centers for Disease Control (CDC) and the British Health Protection Agency. Any public health intelligence must be funneled down to regional, state and local health departments and health care systems. The CDC, for example, utilizes an effective Health Advisory /Health Alert System (HAN) which provides valuable information to public health authorities and health care providers.
Emerging (and re-emerging) infectious diseases (EIDs) have great international security and policy implications. With on-going geopolitical instability, and the ever-present threat of asymmetric warfare and terrorism, any small or large outbreak of infectious disease should be evaluated as a potential act of biowarfare or bioterrorism. Forensic epidemiology must be integrated with conventional outbreak epidemiology, until it can be ascertained that an infectious disease outbreak is natural in origin. Public health surveillance needs to be more than routine in our post-9/11 climate. It needs to foster a tactical, strategic and counterterrorism mindset.
We must be prudent in recognizing that infectious agents may be properly cultivated, processed and weaponized as Weapons of Mass Effect (WMEs) for terrorism or tactical and strategic biowarfare by terrorist factions and rogue nation-states, not to mention major nations with proven capabilities for bio-warfare (BW) research, development and deployment, such as Russia (former Soviet Union Biopreparat program).
The use of a viral agent, such as MERS–CoV, is not exempt from the realm of deliberate and “deployable diseases”. Appropriate planning and preparedness for natural outbreaks will assist greatly in preparing for bioterrorism contingencies and vice versa. Crucial in both natural and intentional outbreaks are the accrual rate of new cases, geographic clustering, syndromic surveillance methods, and the likelihood of quick and accurate clinical diagnosis in the front lines of health care. The latter requiring the education and training, sometimes “just-in–time” training of front-line health care workers, including pre-hospital emergency medical service personnel.
In addition, accurate and adequate risk communication to the public, first responders and health care personnel, while avoiding the possibilities of rumors by the media, the induction of panic, subsequent social disruption, as well as overwhelming health care systems with undue patient influxes of “worried well” individuals. Assessing available resources for public health/epidemiological emergencies is an on-going and critical process, and projections based on trends, simulations and lessons learned must be taken into account.
The current global experience with MERS, serves as a case in point, where planning, preparedness, mitigation and response capabilities must continue to be well-coordinated, robust and aggressive ,and be able to “think outside the proverbial box”.
Introducing MERS: From Saudi Arabia to Your Doorstep
During the summer of 2012, in Jeddah, Saudi Arabia, an obscure, unknown coronavirus (CoV) was discovered and isolated from the sputum of a patient with acute pneumonia and renal failure. Initially, the isolate was dubbed “coronavirus Erasmus Medical Center (EMC).”
In September 2012, the same virus, named “human coronavirus England 1”,was recovered from a patient with severe respiratory illness (SRI), a transfer from the Middle East to the United Kingdom (London). The onset of the disease was then traced back to April 2012, where a cluster of pneumonia cases in health care workers (HCWs) had occurred in the ICU of a hospital in Zarqua, Jordan. In this cohort, two persons died, both infected with the novel strain of CoV.
The morbidity and mortality of this CoV strain proved to be alarming, with, once again, global implications. The original reservoir for the novel strain has been associated with subtypes found in camels. Therefore, the connection can be made that the infectious agent, is capable of a trans-species jump between animal and humans, much like the SARS-CoV among civets in China. The distinction as to whether MERS can be transmitted to other species, and possibly result in either a lesser or greatly enhanced virulent mutated strain in another animal reservoir, has not been fully ascertained. In light of the global experience with the lethal SARS-CoV, which had originated in China, this brought upon newly founded concerns regarding the virulence and potential spread of this novel strain.
The infectious agent is geographically linked to the Middle East, with cases originating from Jordan, Saudi Arabia, Qatar, and the United Arab Emirates. Patients originally exposed and infected outside of the Middle East, include two individuals infected in the United Kingdom via contact exposure to an index patient after the latter returned from Pakistan and Saudi Arabia. A French tourist returning from the UAE became ill and transmitted the infection to another patient with whom he shared a hospital room. This example vividly demonstrates the need for the strictest clinical isolation and, possibly widespread voluntary community quarantine, such as social isolation. The required use and widespread availability of masks patients suspected of any respiratory illness upon entry into health care facilities should be recommended.
Obviously, the need for adequate personal protective equipment (PPE) and countermeasures for first responders and HCWs, e.g. respiratory protection, body substance isolation (BSI), adequate hand-washing, reduction/containment of aerosol production during the administration of certain therapeutic modalities, such as tracheal suctioning, induced coughing and nebulization treatments are self-evident. In an extensive public health emergency involving a highly lethal bio threat agent/emerging infectious disease mandatory quarantine protocols and procedures, under public health laws, may be imposed to curtail the chain of infection and infectious spread.
MERS has arrived in the U.S., with the first confirmed case on May 2, 2014, in a traveler from Saudi Arabia to the U.S.. On May 11, 2014, a second U.S. imported case of MERS was confirmed in a traveler who also came from Saudi Arabia. On May 16, 2014, an Illinois resident who had contact with the first case of MERS in the US tested positive for MERS-CoV, as per the U.S. CDC.
Healthcare professionals should evaluate for MERS-CoV infection who meet certain criteria. These US CDC criteria include fever and pneumonia or acute respiratory distress syndrome (ARDS) based on either clinical or radiologic (X-ray) evidence, and EITHER:
• History of travel from countries in or near to the Arabian Peninsula within 14 days before symptom onset
• OR close contact with a symptomatic traveler who developed fever and acute respiratory illness (NOT necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula OR
• Is a member of a cluster of patients with severe acute respiratory illness (e.g., fever and pneumonias requiring hospitalization) of unknown etiology in which MERS–CoV is being evaluated in consultation with state or local health departments
• OR Close contact of a confirmed or probable case of MERS, OR other possible community contacts OR contacts made via transportation modes, such as bus, train, airplane.
• Positive results for another respiratory pathogen DOES NOT preclude testing for MERS-CoV, due to the possibility of co-infection.
• There is no vaccine yet available for immunoprophylaxis against MERS-CoV.
MERS-CoV and other emerging infectious diseases continue to pose credible threats to global public health and international security. The need for increased and improved medical and public health intelligence and real-time, on-going surveillance is essential. Development and implementation of guidance and methodologies/tools for “grass roots” field epidemiology by local public health assets must be among the priorities. Improving global laboratory capacity and diagnostics to speed and enhance identification and confirmed diagnosis is crucial in addressing the response to novel infectious diseases. Providing expert recommendations for infection control for the public and health care providers to prevent infectious spread is of paramount importance.
Public health education, training guidance and support for transportation systems, EMS systems at all levels, border protection and customs authorities, and the ability for unfettered reporting to health authorities are vital components. Maintaining a system of updated and accurate information to the general public will do much to dispel rumors and offer ways for self-protection and prevention of disease dissemination.
In terms of overall biodefense strategies, the ability to be farsighted and foresee and integrate criminal and terroristic intent into overall preparedness and response activities would be prudent, and should be automatic when addressing a global health threat such as a novel infectious disease strain.
Frank G. Rando is a clinician, educator trainer, first responder and crisis and emergency manager with over 30 years of experience in health care, pulmonology and critical care medicine, biomedical sciences, emergency medical services, public health and safety, environmental safety and health, homeland security and counterterrorism. Frank is a Subject Matter Expert ,consultant and instructor in tactical and disaster medicine ,healthcare and public health emergency management ,environmental safety and health, counterterrorism, disaster epidemiology, crisis and disaster management He continues to serve in various consultative and instructional and exercise evaluation roles for academic, private and public/governmental sectors.