June 30, 2014
Flawed Response By Saudi Arabia Cited In Outbreak Of Middle East Virus; The Next Global Pandemic Could Be Downloaded From The Internet
Ben Hubbard and Donald McNeil have a front-page article in this morning’s (June 30, 2014) New York Times with the title above. They write “as the virus tore through the city’s [Jidda] largest hospital, jumping from bed to bed, and afflicting scores of people, — terror [and panic] filled the wards. Some doctors and nurses refused to treat the sick; and/or, stopped coming to work altogether. Patients panicked. One surgeon recalled a man with a broken limb, trying to flee the emergency room — so, he would not catch it also.” “Everyone was afraid,” said Saudi surgeon, Dr. Mohammad Ahmed. “It was the darkest hour,” writes Mr. Hubbard, and Mr. McNeil, “since the illness — known as Middle East Respiratory Syndrome, or MERS, first appeared in Saudi Arabia in late 2012.” “In all,” they write, “more than 700 cases have been documented in 20 countries; and, nearly all of them linked to Saudi Arabia. More than 250 of those infected — have died from the virus. The sudden spread of a fatal new virus is reminiscent of the early days of SARS (Severe, Acute, Respiratory Syndrome) — a related disease that appeared in dozens of countries — and, killed more than 770 people — mostly in Asia in 2003.”
“MERS circulates most heavily in a region that is the nexus of Islam,” the authors note. “The port city of Jidda is the arrival point for most of the two to three million pilgrims who make the hajj to Mecca each year. Riyadh, Saudi Arabia’s capital and second largest city — also had the second largest outbreak after Jidda, and also some cases in Mecca. Although the hajj will not occur till October, off-season travel by pilgrims to the region have facilitated the spread of the virus to Iran, Jordan, and Algeria.”
“While Saudi officials claim to have the disease under control, Mr. Hubbard and Mr. McNeil note that “the number of cases and deaths have more than tripled since the end of 2013,” leading to severe criticism regarding how Saudi authorities are handling the outbreak. A World Health Organization Panel said earlier this month that the surge in cases that began in April had subsided, but that “the situation remains serious;” and, that hospital outbreaks should be investigated for breaches in safety protocols.”
“I am not saying we’re not worried, but this is something that can be controlled,” said Hanan Balkhy, Executive Director for Infection Prevention and Control, at Saudi Arabia’s National Guard Hospitals. “If this were Ebola, I would go to the King himself and tell him, “we need to isolate the Kingdom.”
“Both SARS and MERS are coronaviruses, named for their shapes. Both are thought to have originated in bats; and, then spread through other animals [camels], to humans. But while SARS circulated in obscure forest animals like palm civets that are eaten in southern China,” the authors note, “MERS infects camels, which are common in the Middle East. MERS, they write, “seems to jump more easily to humans, possibly in raw camel milk, — but, [thankfully] it spreads less readily between people than SARS did.” “One theory gaining popularity,” they add, “is that MERS cases peak in the Spring, because camel calves are born at that time.”
But, “lapses in the Kingdom’s health system played a bigger role in spreading the virus than camels did. Most of the hundreds of new infections were linked to hospitals, dialysis clinics, or health facilities; and, many were among [hospital] staff members. The greatest number of new cases was at the King Fahd Hospital in Jidda. Doctors said a mix of bad management, crowding, and lax hygiene — helped spread the virus there. Moreover, suspected MERS cases were not always identified and isolated and, patients unwittingly spread the virus around the hospital — one in a cardiac ward, and another among dialysis patients,” according to Dr. Ahmed Ragab, Chief of the Hospital’s Intensive Care Unit. “If one patient came in with the virus, all the others would get it — because they were all next to each other,” added Dr. Ragab. Additionally, some medical staff members were lax with sanitary measures, not wearing masks or, infrequently washing their hands. Many, subsequently fell ill,” wrote the authors.
“Whether Saudi Arabia can get the virus under control will depend.” experts say, “on how effectively [best hygiene practices] new sanitary measures can be applied nationally — not an easy task in a country of long distances and weak government oversight of some health centers.” Thankfully, the authors note that “the number of new cases reported nationally appears to be falling, with about 200 in May; and, only 27 since then,” the Health Ministry said. “The most direct cause of this improvement — after, of course, the blessing of Allah — is the stringent implementation of infection control in hospitals,” said Tariq Madani, who heads the Saudi Health Ministry’s MERS Task Force.”
Reminds me somewhat of the 1969 sci-fi novel by the late Michael Crichton — The Andromeda Strain. The book was made into a movie in 1971, detailing the efforts of a team of scientists investigating a deadly, extraterrestrial microorganism — which rapidly, and fatally clots human blood, while inducing insanity in some people. The organism ‘hopped a ride’ on a military satellite that had recently returned to Earth. But, it isn’t the threat of a deadly extraterrestrial virus that has some scientists and medical doctors worried.
The Next Global Pandemic Could Be Downloaded From The Intenet
Marc Lipsitch, a Professor of Epidemiology and Director of The Center for Communicable Disease Dynamics at the Harvard School of Public Health, has an article in today’s (June 30, 2014) New York Times, “Anthrax? That’s Not The Real Worry, warns that laboratories in the U.S. and around the globe are working with virulent flu strains that could inadvertently start a pandemic. “These experiments,” he writes, use flu strains like H5N1, which kills up to 60 percent of humans who catch it from birds.” “The problem,” he writes, is that such experiments themselves, risk spreading virulent flu in the population; and, perhaps even causing a [global] pandemic.”
Mary McKenna, writing in last month’s Wired.com, “The Next Global Pandemic Could Come From The Internet,” wrote that “the controversy centers on what’s called “gain of function research. “In the case of flu,” she writes, “what is being gained (via lab manipulation) is the ability for the flu to transmit easily from one lab animal to another. The strains being manipulated are already virulent, that is, causing severe illness; and novel, — that is, humans have never experienced them before, and so have no immunity to them. Adding transmissible to virulent and novel brings flu into the territory of potentially becoming a potential pandemic strain. That’s where the controversy is.”
“The controversy over “gain of function research,” Ms. McKenna writes, “dates back to 2011, when Ron Fouchier at Erasmus Medical Center in the Netherlands, and Yoshihiro Kawacka at the University of Wisconsin — both disclosed their labs were tinkering with the H1N5 strain of avian flu. At that point, public health had been watching H5N1 for about six years, as it spread slowly from southeast Asia. The strain caused severe illness, killing up to two-thirds of people made sick by it, but except in rare instances — only occurred in people who had some direct contact with poultry, and did not transmit easily person-to-person. The discoverability that transmissibility was being added to the virus’s toolkit, even if just between ferrets in the confines of moderately high-security labs, caused an uproar. The quasi-governmental National Science Advisory Board for Biosecurity, examined both papers and, very unusually, recommended the details be stripped from them before they were published. The fight that occasioned — held up both papers, as details were argued over, but they were eventually both published in full, Fouchier in the Journal Science, and Kawacka in the Journal Nature, in mid-2012.
“The research met with such an outcry, that the two scientists and 38 other prominent flu researchers announced a voluntary moratorium on “gain of function,” studies throughout 2012 — but then announced in 2013, to more outcry and disengagement, that they were going to resume,” she notes. “Since then, those teams and others have proposed gain-of-function studies on H7N9 avian flu, and more recently on H7N1 avian flu. “Gain of function” research being conducted in the U.S. is now subject to some pre-publication review — but, that review, for instance, didn’t prevent the H7N1 paper from being published, even though some reviewers felt the benefits of research did not outweigh its risks. Several of those reviewers proposed last month that a national board be set up specifically to conduct such pre-publication reviews in the United States. Two weeks ago, a similar proposal was made in Germany, and the implications for “gain-of-function research were also recently examined in the French newspaper, The Le Monde.”
Ms. McKenna observes that, “none of the scrutiny has significantly deterred the gain-of-function researchers though and, — that’s where last week’s paper comes in. The authors, Marc Lipsitch of Harvard, who has persistently criticized the “gain-of-function” studies, and Allison Galvani of Yale argue that the research is so inherently dangerous — that it requires an independent, comprehensive, risk-benefit analysis that should be made public before any more studies are undertaken.”
“One often-cited criticism of these studies is that the infected lab animals could pass the enhanced strains to a lab worker, who would then spread the accidental infection — with the novel virus to others. Lipsitch and Galvani take that possibility seriously enough to work out the math, and the probabilities they come up with are daunting:
— “These studies have typically been conducted in biosafety level (BSL-3) 3, or 3+ containment facilities. Laboratory-associated infections for BSL-3 facilities are conservatively estimated to occur at a rate of two per 1000 laboratory-years in the U.S., where protocols and enforcement are relatively stringent. Globally, high-containment laboratories have variable standards and enforcement. Experimentation is less-regulated, or un-regulated laboratories, with the attendant risks of accidental or deliberate release, is facilitated by the publication of sequence and functional data on PPPs, and even if the original research was conducted with state-of-the-art safety and security.”
— “From the conservative estimate of the rate of laboratory-associated infections of two per 1000 laboratory-years, it follows that a moderate research program of ten laboratories at BSL3 standards for a decade — would run a nearly 20 percent risk of resulting in at least one laboratory-acquired infection, which in turn, may initiate a chain of transmission. The probability that a laboratory-acquired influenza infection would lead to extensive spread — has been estimated to be at least 10 percent. Simple branching process models suggest a probability of an outbreak arising from an accidental influenza infection in the range of 5 percent to as much as 60 percent.”
“As alternatives to the current “gain-of-function” studies, Lipsitch and Galvani recommend a menu of experimental approaches that they contend would be both safer and more informative: modeling, sequence comparisons from existing databases, single-protein studies and, examination of lab-constructed resistant strains that would retain the viral-surface proteins to which some human immunity exists.”
Ms. McKenna concludes that, “probably, predictably, the researchers who first advanced the gain-of-function studies, dismiss the critique.” “What’s more important though,” she argues, “is whether these proposals will stimulate a re-examination of the risks of gain-of-function studies among governments, funders, and the universities hosting the labs. The possibility of a lab escape may be lower than the authors estimate — but, the results are so potentially dire — that it would be important to know that running the risk is worthwhile. Lots to think about.
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