International Public Health Concerns - Not So Foreign

by Robert C. Hutchinson

Public health policy articles published in the November 2013 and March 2014 issues of the DomPrep Journal examined emerging and evolving pathogenic threats around the world to evaluate U.S. preparedness levels for serious novel illnesses. These public health concerns continue to expand and highlight the consistent and diverse threats that are only a short flight away within a globalized economy. Sooner than many expected, the Centers for Disease Control and Prevention (CDC) reported that the first case of the Middle East Respiratory Syndrome (MERS) virus arrived in the United States on 2 May 2014 via commercial air travel within the body of a healthcare worker travelling from Saudi Arabia. A hospital in Florida diagnosed the second case of MERS on 9 May 2014 in another healthcare worker from Saudi Arabia who was visiting relatives in the United States. The immediate effect of the MERS arrival reportedly has been minor and well addressed by medical and public health professionals, thus providing another significant opportunity to evaluate the nation’s plans and capabilities.

Emerging Threats & Growing Drug Resistance On 3 April 2014, the CDC and the Minnesota Department of Health confirmed a diagnosis of another foreign pathogen – Lassa fever – in a person returning to the United States from western Africa. Although it is not the first domestic occurrence of the virus, Lassa fever has been rare in the United States. As with many other pathogenic concerns such as MERS, Lassa fever emerged in a very short time period via international commercial air travel. The diagnosis of both MERS and Lassa fever required theentification of common travelers and associates to determine any further exposure and possible spread of the illnesses. In the aviation environment, exposure possibilities could be exponential due to the length of flights and number of interconnected passengers throughout the world.

Domestic public health concerns include more than emerging viral threats, but also parasites that are often considered public health concerns in developing nations. The CDC has targeted five neglected parasitic infections in the United States because of the severity of the illnesses, the number of people affected, and the nation’s ability to prevent and treat these infections. According to a CDC press release on 8 May 2014, “the [neglected parasitic infections] in the United States are part of the global burden of parasitic diseases, and strategies that reduce or eliminate them in the United States can someday be applied globally.”

These microbial arrivals and occurrences merit even greater observation and consideration as reports of antiviral and antibiotic resistance increasing throughout the world – especially in the developing world – continue. The ability to purchase antibiotics without prescriptions in many nations provides easy access for a large number of people to find an immediate benefit, but with potential consequences later. The frequent prescription of antibiotics in developed nations for viral infections also is not helpful by expanding this resistance. Unfortunately, an unintended consequence of such easy access, as well as the frequent and repeated exposure to these lifesaving pharmaceuticals, is an accelerated microbe resistance.

Strategic National Guidance These most recent developments have again initiated policy and planning questions regarding realistic preparedness for biological threats, which includes naturally occurring pathogens. All-hazards strategies and plans, with a focus on this subject matter, continue to drive planning and preparedness. President George W. Bush issued Homeland Security Presidential Directive 21 (HSPD-21), entitled “Public Health and Medical Preparedness,” in 2007 to update the national strategy. Issued after the more pandemic influenza-focused National Strategy for Pandemic Influenza (2005), National Strategy for Pandemic Influenza – Implementation Plan (2006), and HHS (U.S. Department of Health and Human Services) Pandemic Influenza Plan (2005), HSPD-21 was intended to protect the health of U.S. citizens against all disasters. This directive provides high-level guidance for biosurveillance, medical countermeasures, and other topics relevant to current emerging pathogenic threats. The document also is useful for understanding and measuring expectations and responsibilities in order to develop or enhance organizational strategies, policies, and plans.

Under President Barack Obama’s administration, Presidential Policy Directive-2, entitled “Implementation of the National Strategy for Countering Biological Threats” (2009), is another important high-level strategic directive for reference and review. The president’s National Strategy for Countering Biological Threats (2009) is a broad strategy for addressing the vast world of biological threats in conjunction with other associated national strategies and plans. Included in the strategy is the rapid detection and containment of serious infectious disease outbreaks and the improvement of international capacity against communicable diseases to better prepare national capabilities.

The first-ever National Strategy for Biosurveillance (2012) builds on the previous strategies, plans, and capabilities toentify and understand threats as soon as possible, including the spread of infectious diseases. This strategyentifies the following four enablers for strengthening biosurveillance relative to the current emerging and evolving pathogens:

  • Integrate Capabilities – Emphasize efforts to transcend regular boundaries and extend across traditional organizational lines;
  • Build Capacity – Integrate fusion centers, law enforcement, intelligence, and other information and collection activities;
  • Foster Innovation – Encourage new thinking and develop revised methodologies aimed at forecasting outbreak trajectories in the absence of definitive data; and
  • Strengthen Partnerships – Develop connections through collaborative international biosurveillance activities that will accelerate operational response to domestic and international incidents.

As re-enforced in the recently released (18 June) 2014 Quadrennial Homeland Security Review, “Of the naturally occurring events, a devastating pandemic remains the highest homeland security risk.”

Globalization & Preparedness The National Strategy for Biosurveillance concludes that protecting the health and safety of the people in the United States through a well-integrated national biosurveillance enterprise is a top national security priority. The challenge is to confirm that this top strategic priority has effectively cascaded down through all levels of the public and private sectors to meet the ever-changing threats of today and tomorrow. If MERS or Lassa fever arrived in a mutated strain with sustained person-to-person transmission or within a SARS-like (severe acute respiratory syndrome) human superspreader, the nation’s plans and true preparedness would be significantly tested – possibly to failure.

Through the globalization of trade and travel, pathogenic threats that appear foreign based on knowledge, experience, or physical distance may be much closer than many would think. It is important to appreciate these currently manageable reminders of MERS and Lassa fever before the arrival of a more serious pandemic microbe or an unthinkable hemorrhagic fever such as Ebola or Marburg. These public health threats may appear quite remote and distant, but so did MERS and Lassa fever to many practitioners and policymakers several months ago. A significant and overwhelming public health threat may be just a short flight or bus ride away.


The opinions expressed herein are solely those of the author in his individual capacity, and do not necessarily represent the views of his agency, department or the United States government.

Robert C. Hutchinson is a supervisory special agent (SSA) with the U.S. Department of Homeland Security, U.S. Immigration and Customs Enforcement’s Homeland Security Investigations. He was previously the deputy director and acting director for the agency’s national emergency preparedness division. He has lectured internationally on this subject and advised national representatives from the Middle East and Central Asia regarding policy development. He earned his graduate degrees from the University of Delaware in public administration and Naval Postgraduate School in homeland security studies.