Infectious disease expert Dr. Mark Kortepeter discusses the need for a better U.S. system to screen for travel-related illnesses and the pathogens stored in laboratory freezers, among other measures.
We tend to have short memories, especially when it comes to prevention of calamities, and the pandemic is no different. The newly discovered omicron variant presents us another Covid-19 hurdle to cross. There will be more. If we wait to close borders and shut down flights after something new is identified, that’s like pulling up the drawbridge after the contagion has already entered the castle walls – too late to prevent further spread. Two recent events show the holes remaining in our pandemic preparedness plans.
The First Event: Monkeypox in Maryland
In mid-November 2021, the Maryland health department reported a case of monkeypox in a U.S. citizen returning from Nigeria. Although the reports are skimpy on details, making it difficult to know the patient’s stage of infection at the time of travel, it prompted health officials to hunt down the fellow passengers to put them under surveillance for possible exposure. This was the second imported case this year (there was one in Texas in July also after travel to Nigeria). Monkeypox occurs in parts of Africa and spreads to humans from animals, and it can also spread person-to-person. Patients can have a similar appearance as smallpox, making a case of it cause for concern, but it is not as deadly. Initially, a patient may complain of fever, headache, muscle aches, swollen lymph nodes, and fatigue, then after a couple days the infection manifests with large pockets of pus on the skin all over the body, including the face and hands.
It would be impossible to look at someone and discern whether they were infected with the omicron Covid variant, the common cold, or any other respiratory virus, but a fifth grader could pick someone suffering from monkeypox out of a crowd. Somehow the individual made it past customs, immigration, and airline authorities. If we didn’t realize it before, Covid should have reminded us repeatedly that we need a long-term strategy, not a knee-jerk response for managing pandemic risk at our airports, ports, and borders. Even before the U.S. shut down air travel from eight countries in Africa, anyone in public health could have told you omicron was likely already circulating within U.S. borders.
The Second Event: Smallpox-labeled Vials in Pennsylvania
The second event was reported during the same week in November 2021. Vials labeled “smallpox” were discovered in a Merck vaccine research facility in Pennsylvania. The FBI swooped in, and the CDC tested the vial’s contents and determined that it actually contained a different virus, vaccinia, which is used for vaccinating against smallpox. Regardless, having vials labeled smallpox sitting in a freezer should have been a red flag long ago, because smallpox, which was one of the deadliest infectious diseases throughout history, is also a potential bioterrorism threat (hence the FBI’s involvement). Any cases of smallpox infection would constitute an international public health emergency.
In 2009, the Army biodefense lab at Fort Detrick, Maryland, came under fire due to vials of Venezuelan equine encephalitis virus being found that had not been previously recorded in their database. It prompted a 4-month long inventory of their 70,000 vials of pathogen stocks held in their freezers. The NIH came under similar scrutiny in 2014 after vials of smallpox were found, and a similar breach with anthrax occurred at the CDC. These events should have sounded the alarm among laboratories across the U.S. to clean out their own “attics” and get rid of any vials labeled smallpox or other high threat agents that didn’t belong there years ago.
Contagious diseases move faster than our countermeasures and surveillance systems, and they certainly don’t respect national borders.
Where does this leave us in our preparedness? In August, 2021, the Government Accountability Office (GAO) published an assessment of the United States’ preparedness for the next pandemic. The conclusion was that we are still lacking in a number of areas. Many of the gaps identified from previous pandemic exercises were not followed up. Information sharing and coordination of response operations between government agencies needed work, and problems in obtaining and distributing supplies and medical countermeasures noted in the report have been challenging during the Covid pandemic.
A recent article on lessons learned twenty years after the 2001 anthrax terrorist attack further emphasizes such challenges. There were significant inroads made into preparedness for bioterrorism post-anthrax, which had dual benefits for pandemic preparedness. These included establishment of the office of the Assistant Secretary for Preparedness and Response, the strategic national stockpile, a national laboratory response network, and funding to shore up health departments and hospitals for emergency response. However, the ensuing years saw a lack of preparedness sustainment, with declines in public health funding, the public health workforce, and need for replenishment of the strategic national stockpile. These erosions of capabilities left us vulnerable when Covid-19 arrived.
The GAO report and the recent article about anthrax demonstrate that we still have a long way to go in re-building response capacity in our hospitals and public health institutions, which would benefit from a rigorous review similar to the 9/11 commission, as the anthrax article authors recommend. In addition, by now, we should have a solid method for screening for travel-related illnesses being imported into the U.S. and we should have a better handle on what high threat pathogens are stored away in our nation’s laboratory freezers. The imported case of monkeypox and the discovery of smallpox-labeled vials indicates to me that we still have neither.
Contagious diseases move faster than our countermeasures and surveillance systems, and they certainly don’t respect national borders. It’s time for a comprehensive reassessment of what works and doesn’t work for reducing importation of infectious diseases and what are reasonable screening practices and policies at ports of debarkation during and between pandemics based on scientific evidence. We do plenty of security screening before boarding flights inbound to the U.S. – it seems infectious disease risk merits equal priority. There is no time like the present.
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