Outbreaks: Field Level Response
Outbreaks: Field Level Response
Outbreaks of infectious disease range in size and severity. A prompt response at local—or field—level can limit the spread of an outbreak and help to prevent future episodes. Response is an important component of epidemiology, which is the study of the occurrence of disease among the population. Epidemiology involves surveillance and case reporting, so that outbreaks can be identified. Emergency response can include treatment and isolation measures, but needs to be coupled with a thorough investigation so that the causes of the outbreak can be recognized and halted.
Health authorities need to put in place advance plans for dealing with outbreaks covering the three components of surveillance, response, and investigation. The World Health Organization (WHO) and the Centers for Disease Prevention and Control (CDC) in the United States have developed structures, guidelines, and networks which allow responses to be mounted to infectious disease outbreaks, including deliberate outbreaks of disease due to a bioterrorist attack.
WORDS TO KNOW
EPIDEMIC: From the Greek epidemic, meaning “prevalent among the people,” is most commonly used to describe an outbreak of an illness or disease in which the number of individual cases significantly exceeds the usual or expected number of cases in any given population.
GLOBAL OUTBREAK ALERT AND RESPONSE NETWORK
(GOARN): A collaboration of resources for the rapid identification, confirmation, and response to outbreaks of international importance.
ISOLATION: Isolation, within the health community, refers to the precautions that are taken in the hospital to prevent the spread of an infectious agent from an infected or colonized patient to susceptible persons. Isolation practices are designed to minimize the transmission of infection.
NON-GOVERNMENTAL ORGANIZATION (NGO): A voluntary organization that is not part of any government; often organized to address a specific issue or perform a humanitarian function.
PATHOGEN: A disease causing agent, such as a bacteria, virus, fungus, etc.
SURVEILLANCE: The systematic analysis, collection, evaluation, interpretation, and dissemination of data. In public health, it assists in the identification of health threats and the planning, implementation, and evaluation of responses to those threats.
The English physician John Snow (1813–1858) demonstrated one of the earliest recorded responses to a disease outbreak. In 1854, he began to investigate an outbreak of cholera in his local area of London. He constructed a detailed street map showing the location of cases and deduced that the source of the infection was the local water pump.
He either removed the pump handle himself, or ordered it to be removed, and shortly afterwards, the number of cholera cases began to decline. It is not possible to prove that Snow's action, in itself, limited the outbreak—it may have been on the decline naturally— but the principle of removing the cause of the infection was correct. It is this same principle which guides effective field response to outbreaks today.
A field response to an outbreak occurs at a local level and often involves the facilities of the nearest hospital, particularly its emergency department. The hospital needs to have sufficient capacity to deal with an outbreak in terms of medical supplies, such as vaccines and anti-biotics, trained medical staff, and beds to care for seriously ill patients. Naturally, many hospitals may not have this capacity on site, but they must be able to access it if necessary.
Adequate and prompt communication between the hospital, primary care, the emergency services or public health organization, and the media is essential while responding to an outbreak. The local health authorities have detailed plans for responding to an outbreak at the field level, and this is tested in simulation exercises to identify gaps and weaknesses. As infectious agents know no boundaries, states and countries work together to respond to an outbreak.
Countries, especially developing countries, cannot be expected to deal with outbreaks of infectious disease on their own. In 2000, the World Health Organization set up the Global Outbreak Alert and Response Network (GOARN), which is a collaboration of over a hundred technical institutions, non-governmental organizations and networks, creating a pooled resource for alert and response operations.
Investigative teams from GOARN will arrive at the site of an outbreak within 24 hours. They will offer on-the-spot investigation, confirmation of diagnosis, handling of dangerous pathogens (disease-causing organisms), case detection, patient management, containment, and provision of staff and supplies. All of these elements are needed to safely contain an outbreak, but many may not be available on site.
Since early 2000, WHO and GOARN have launched international responses to disease outbreaks in countries around the world including Afghanistan, Bangladesh, India, Pakistan, Sudan, Tanzania, and Uganda. Recently, WHO has strengthened GOARN's outbreak response logistics with specialized transport and communication facilities, which are particularly valuable in areas with weak local infrastructures. Many other non-governmental organizations (NGO), such as the humanitarian group Médicins sans Frontières, and national health authorities, like the Centers for Disease Control and Prevention (CDC), also get involved responding to situations in developing countries.
In a recent report, WHO describes its involvement in dealing with an outbreak of meningococcal meningitis in Burkina Faso. In the early months of 2007, the Ministry of Health in Burkina Faso reported 22,255 suspected cases including 1,490 deaths, meaning that 34 districts were over the threshold considered to be an epidemic. Cerebrospinal fluid samples from all affected areas tested positive for the bacteria Neisseria meningitides. This lab work was essential for describing the extent of the outbreak, implying what needed to be done to contain it.
A vaccination campaign was completed in 15 districts, reaching 100% of those at risk, and was ongoing at the time of the last report. The vaccine came from an international stockpile, which was able to supplement those held by the Ministry of Health of Burkina Faso. Financial support for the vaccination campaign was forthcoming from the international community via many non-governmental organizations, such as the United nations Central Emergency Response Fund and the United States Agency for International Development.
Response to outbreaks in countries with well-developed health infrastructures is usually coordinated by a national body, such as the CDC's Emergency Preparedness and Response Department, or the Health Protection Agency in the United Kingdom. Typical incidents might include food poisoning or measles outbreaks, and response would be part of the surveillance, case reporting, and investigation strategy. The response might involve actions such as closing schools, child care centers, or restaurants to eliminate the cause of the infection or limit its spread.
Public information dissemination is an important part of response to an outbreak at field level, including warning people of symptoms and advising them on how to avoid infection. Medical treatments include vaccination, drug administration, and hospitalization, but the specifics depend upon the illness involved in the outbreak.
The most testing situation for an outbreak response team is when a new or unusual infection is involved. Thus, the manner in which outbreaks of severe acute respiratory syndrome (SARS) and H5N1 avian influenza have been dealt with in recent years has come under scrutiny. The WHO commented on some aspects of the way the Ministry of Health of China handled an outbreak of SARS among laboratory workers in 2004. The response was judged, overall, to have been prompt with isolation of cases and tracing of possible contacts, although there was delay in identifying the early cases and initially, there was secrecy towards fellow citizens and the international scientific community. The Chinese Ministry of Health later stated it would learn from this outbreak and further strengthen its response system for the future.
Current research includes developing vaccines for use before and during outbreaks of disease (such as two vaccines approved in 2006 that protect against rotaviruses, a common cause of diarrhea outbreaks), developing effective and inexpensive personal protective equipment for responders and community members, and especially, developing rapid diagnostic tests to identify particular pathogens and diseases in the field during the initial stages of an outbreak.
When it comes to outbreaks of well-known diseases, such as Salmonella food poisoning and meningitis, public health authorities are well-practiced in mounting a response. However, there are new threats, from emerging diseases such as H5N1 avian influenza to the possibility of bioterrorist attacks. A major issue is whether there is the capacity and preparedness within the health system to deal effectively with these.
In 2003, the United States General Accounting Office (GAO) conducted a survey of major hospitals to find out more about their public health response capacity. This showed that bioterrorism preparedness efforts mounted since the terror attacks of September 11, 2001, had indeed improved overall response capacity, but gaps remained. These included workforce shortages and shortfalls in laboratory capacity to deal with an emergency situation. There was also a lack of planning between states.
The GAO did find that states had plans for receiving and distributing medical supplies (even if these were not on site) and plans for mass vaccinations. Staff had participated in basic planning for large infectious disease outbreaks, but some hospitals lacked sufficient isolation facilities and staff to treat a large increase in the number of patients that might result from an emergency outbreak of influenza or a bioterrorist attack.
In 2003, as a serious new infectious disease threat (SARS) emerged in China, the Chinese government initially took measures to keep the outbreak a secret. Only after the disease spread beyond the borders of China and a few journalists and physicians found a way to communicate the urgency of the disease to the international scientific community did fully coordinated field-level response to the SARS epidemic begin. By this time, there were multiple outbreak sites requiring response. In this excerpt from the magazine Foreign Policy, Karl Taro Greenfeld unravels the story of how the mystery disease was communicated to the world. At that time, Greenfeld was the editor of Time Asia in Hong Kong, and has since published a book about the emergence of SARS in China entitled China Syndrome: The True Story of the 21st Century's First Great Epidemic. China has now adopted a policy of international cooperation and participation in networks that report, track, and respond to outbreaks of infectious disease.
The Virus Hunters: When the Deadly SARS Virus Struck China Three Years Ago, Beijing Responded with a Massive Coverup. If It Weren't for the Persistence of Two Young Reporters and One Doctor Who Had Seen Enough, SARS Might Have Killed Thousands More. There's No Guarantee the World Will Be So Lucky Next Time.
In April 2003, as thousands of Chinese were infected and the dying were quarantined in squalid hospital wards, the Chinese government covered up the SARS outbreak, allowing the killer virus to spread around the world. That was hardly surprising. The first response to an epidemic is usually denial. From the perspective of a head of state, a mayor, a governor, or any ruling body, infectious disease remains among the hardest issues to manage. There is almost no calamity, save starvation or siege, that can so quickly reduce a city to panic and despair. Why should China's mandarins behave any differently? When confronted with a new infectious disease caused by the SARS virus, they initially downplayed the danger and assumed a tacit policy of wishing the microbe back into whatever species from which it had jumped. What did they really have to go on at first? A few hundred cases? In a nation of more than a billion? Indeed, with infectious disease outbreaks a far more common occurrence in China than in, say, the United States, it is on one level understandable how China's minister of health, Zhang Wenkang, could have initially downplayed the threat posed by a respiratory infection thousands of miles from the capital. If it hadn't jumped international borders, then the outbreak might have remained a minor medical curiosity.
Yet the SARS epidemic of 2003 now appears a useful blueprint of how the next pandemic might begin. As the planet struggles to deflect another imminent viral emergence, the lessons learned from SARS are more relevant than ever. Although the work of virologists, physicians, nurses, and public health officials was instrumental in beating back the virus, it is frightening to consider that if it weren't for the courage of one iconoclastic Chinese physician who came forward to tell the truth at enormous personal risk, the SARS epidemic would have been even more devastating….
A BITTER DISCOVERY
He had watched this before, 71-year-old Dr. Jiang Yanyong recalled. He hd seen the best and the brightest brought down because of a lie, for the government's prevarications, recalcitrance, and duplicity. Jiang had been on duty the evening of June 3, 1989, when the People’ Liberation Army (PLA) massacred the students in Tiananmen Square….
Today, Jiang holds a military rank equivalent to general because of his title as chief of surgery at the hospital. For a moment, when you first see him, you think he must be in his 50s—his hair is an unnatural crow black—but there is an age droop to his eyes, as if the ocular muscles themselves have worn out from squinting into so many surgical incisions.
Throughout March 2003, Jiang had been spending more time indoors, like many people around the world, watching television for news of the war in Iraq. The SARS virus was only a crawl on China Central Television (CCTV), a glowing proclamation that “SARS is under control and there has never been a better time to visit Guangdong Province.” The SARS outbreak has so far been reported as primarily a Hong Kong problem; the disease, if it were in China at all, had probably been brought in by foreigners, the official Chinese media were reporting.
Among international public health officials, of course, there was increasing consensus that the outbreak in China was far worse than the Chinese government was admitting. The State Council Information Office was reporting 12 SARS cases and 3 fatalities in Beijing. It seemed impossible: There were thousands of cases in Guangdong and Hong Kong, and hundreds in the provinces throughout China. How could Beijing have just 12 cases? Jiang found that discrepancy curious but gave it little thought.
But near the end of that month, a good friend of Jiang's fell ill with lung cancer and, naturally, Jiang was brought in to consult on the case. The patient, a medical professor, was brought to 301 Hospital. Surprisingly, he developed a high fever and a spot was found on his lung. After another specialist was brought in, Jiang's friend was diagnosed with SARS and transferred to the intensive care unit before he was removed and sent to 309 Hospital, deemed the official SARS Control and Prevention Center for the People's Liberation Army. Jiang, checking on the treatment his friend might receive, phoned respiratory specialists at 309 who were former students of his from Beijing University Medical College. “They sounded very upset,” Jiang recalls. “I didn't understand why. There were just a few cases and that was such a big hospital.”
There were 60 cases, Jiang was told, dozens of them medical staff themselves. Seven patients had already died of the disease. He called other colleagues and found that there were similar outbreaks occurring at 302 Hospital, which had 40 cases, and even at his own 301 Hospital, which had 46 SARS cases. “This is a terrible disease,” one of his colleagues told him. “It acts so quickly. I've never seen any disease progress this fast. You go from breathing normally to intubation in three days. You die in a week.”
Why, then, did the health minister, Zhang Wenkang, appear on television on April 3 to reassure the public that there were only 12 cases in all of Beijing, when there were 60 in just one hospital?…
…Jiang decided to pen a note, explaining who he was and the facts about the number of SARS cases in the No. 301, No. 302, and No. 309 hospitals. “As a doctor who cares about people's lives and health, I have a responsibility to aid international and local efforts to prevent the spread of SARS.” He faxed it to the government-controlled CCTV-4 and Hong Kong's Phoenix-TV, two of China's biggest networks, using the fax number for viewer comments and suggestions. He assumed they would quickly get in touch with him to check his credentials before airing it. They never called.
THE OFFICIAL NUMBES WERE LIES
Our Beijing correspondent, Susan Jakes, was asked to prepare a file about the general state of the Chinese healthcare system. She had no contacts in the Ministry of Health. Trying to think of a way into the subject, she decided to call a political source. Susie's connections in the dissident community had been useful in the past, but it was unlikely those connections would extend into the Chinese medical community. Still, desperate, Susie called one of her political contacts, Harold, who had ties to party officials.
She asked him if he knew anything about SARS in Beiing.
There was silence on the line. “Call me back from a safe phone.”
Often, in China, we suspected our land lines and even our cell phones were bugged. When we needed to talk specifics about sensitive subjects, Matt or Susie would switch the SIM cards in their phones from a local Beijing number to an international exchange that was billed through a foreign phone company we believed far less likely to be tapped. Or, even safer, the reporter would find a pay phone—which are still common in China— and call from there.
Susie threw on her denim jacket, walked out of the bureau, and hurried to a nearby pay phone.
“I'm going to send you an email,” Harold said when she called him back. “In that e-mail, there will be a URL to a secure Web site. At that Web site, you'll need a password. Type in your old Hong Kong phone number and you will be able to download a Word file. Read that and call me back.”
Susie ran back to the office to check her e-mail. Harold's message had already arrived. Following his instructions, she downloaded the Word document. At the top, it read
Jiang Yanyong, Doctor, and said that he was a longtime Chinese Communist Party member. It also gave his phone number. She read the note. The letter indicated that the number of patients infected with SARS was significantly higher than the official statistics from China's Ministry of Health. It went on to describe at least 60 patients at one Beijing hospital. Most amazing, this letter was signed by this doctor.
She went back to the pay phone and called Harold.
“Who is this guy?”
“He is who he says he is. A doctor. A party member.”
Susie was nervous this letter would be difficult to verify. “Can I call this guy? Will he talk to me?”
“Call him,” Harold assured her. “He's at home.”
Susie knew what she had now had. A big story about a big lie.
Still using the pay phone, Susie called the number on the letter. Dr. Jiang Yaonyong answered.
When she identified herself, Jiang told her, “Everything I want to say is in the letter.”
“But I need to ask you some more questions,” Susie pleaded, “to flesh this out a little bit.”
He paused for a moment, and then, speaking in a lower voice, said, “Okay, let's meet at the teahouse at 4 o'clock in the Ruicheng Hotel, in the western part of Beijing, near the 301 Military Hospital.”
But, when Susie returned to the bureau, she received another call, this one from a labor lawyer she had called the day before asking if he knew anyone who knew anything about SARS.
“Why don't you come to my office right now,” he suggested. “I think I might have something you want to hear.”
When Susie returned from the bureau, she took a taxi to his offices, on the fourth floor of a modern office building, and when she walked in, after he closed the door, he told her that he had a cousin who is a doctor at the Military Academy of Sciences.
“Will she talk to me?” Susie asked.
“No,” the lawyer explained, “But I can call her and you can listen while we speak.”
Susie would later realize that this had been prearranged by the lawyer ad his cousin to screen them from any possible accusations of talking to a foreign reporter and violating a gag order that was handed down on March 7 forbidding doctors and public health officials from talking to the media about SARS. As for the veracity of the source, we had worked with this lawyer before on several stories, and found him to be reliable.
The lawyer dialed his cousin's cell phone.
“Tell me again what you told me before,” he said, handing the phone to Susie.
Susie listened as the doctor spoke of a situation even more terrifying than that described in Jiang's letter. She described the first case to come to Beijing—a woman who had driven from Shanxi and seeded the Beijing outbreak. To Susie's surprise, that had been in early March, during the National People's Congress. The hospital director at the Military Academy of Sciences had told his staff that there was SARS in Beijing, but that no one was to mention a word of it outside the hospital, so as not to interfere with the National People's Congress and leadership transition.
Since then, the woman continued, there were numerous cases at several hospitals. No. 1 and No. 2 hospitals each had dozens of cases. “They are practically filled,” the woman said. And 309 Hospital, specifically mentioned in Jiang's letter, had 40 new cases in just the last week. 301 and 302 hospitals were also being overwhelmed.
The official numbers were lies.
Susie arrived at the Ruicheng Hotel in Western Beijing at 2:45 that afternoon. With each Chinese businessman entering, Susie would glance up, wondering if he were Jiang. When he finally walked in, he paused a moment and then, seeing Susie, the only foreigner, he gestured her with a quick wave to follow him. She took off after him as he headed for a corner of the lobby. He led her through a service entrance, up an elevator, and down a hall, where he asked a hotel employee for directions. Susie realized he didn't know where he was going as he walked into a cafeteria, which, besides clandestine business meetings, was the primary purpose for these little teahouse rooms. Susie's first impression was that he was nervous. But once they ordered and began to chat, he calmed down. He talked about his work as a surgeon, spoke in very clear Chinese, and gave the names of medical procedures in very good English. He was, Susie quickly deduced, exactly who he said he was in the letter.
Finally, Susie asked, “Why did you write this?”
He paused. “As a doctor, I cannot stand by while there is a terrible disease threatening the people and they are not hearing the truth about it.”…
‘WE ARE ASHAMED’
Huang had already tapped out his most obvious contacts. He began calling friends and asking if they knew anyone who worked in Beijing's hospitals or public health sectors, not really expecting to come up with a source. Yet a friend of his suggested a doctor from the China-Japan Friendship Hospital whom he vaguely knew and gave Huang his mobile phone number.
Huang called and quickly explained who he was and that they shared a mutual friend, and what we had learned about the coverup.
The doctor was silent.
Fearing he would hang up, Huang added that what they knew was going to be published anyway, and this was merely an attempt to make sure they had the facts correct.
Huang listened as the doctor took a deep breath and sighed, “It's true.”
The doctor then recounted to Huang the story of the WHO's April visit to the China-Japan Friendship Hospital. The hospital had 56 SARS patients, 31 of whom were doctors, nurses, and other medical workers. A few minutes before the WHO team arrived, a fleet of ambulances pulled into the horseshoe driveway in front of the hospital. The hospital director ordered the stricken healthcare workers loaded onto gurneys, and staff scrambled to move these patients into the waiting ambulances. As the team of WHO experts inspected the hospital, the fleet of white vans took a leisurely tour around Beijing, keeping its deadly cargo of 31 coughing health care workers a secret from the world.
The doctor was now confirming with Huang that this was more than a “hole”; it was a pattern of deception the scope and scale of which were hard to imagine.
Huang asked him, “How could you do this?”
The doctor said, softly, “We are ashamed….”
Karl Taro Greenfeld
GREENFELD, KARL TARO. “THE VIRUS HUNTERS: WHEN THE DEADLY SARS VIRUS STRUCK CHINA THREE YEARS AGO, BEIJING RESPONDED WITH A MASSIVE COVERUP. IF IT WEREN'T FOR THE PERSISTENCE OF TWO YOUNG REPORTERS AND ONE DOCTOR WHO HAD SEEN ENOUGH, SARS MIGHT HAVE KILLED THOUSANDS MORE. THERE'S NO GUARANTEE THE WORLD WILL BE SO LUCKY NEXT TIME.” FOREIGN POLICY (MARCH, APRIL 2006): 153, 42.
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