Thursday, April 30

H1N1 swine flu pandemic threat: While WHO and the U.S. government dithered, Veratect Corporation raced to warn the world

"Requests made over the last five days to WHO spokesmen for a rough chronology of events and interviews with experts have not been answered. Similar requests to the CDC have been turned down."
-- The Washington Post, April 30, 2009 (1)

The chronology mentioned above relates to the progress of swine flu; it's early days to nail that down. But there is another timeline, a sort of chronology of bureaucratic dithering, which is already available.

The Obama White House and the U.S. Departments of Homeland Security and State fell down badly by dragging their feet in reaction to the earliest concrete warnings of an unusual flu outbreak in Mexico. In my last post, on Monday, I voiced my suspicions about the matter. I was not the only person to harbor such suspicions. In an effort to blunt reporters' pointed questions, the White House issued a Q&A on Monday. From the Boston Globe's report on the Q&A:
QUESTION: When did the US learn about the swine flu situation in Mexico?

ANSWER: As John Brennan of the Homeland Security Council indicated in this afternoon’s briefing, we [the White House] did not learn about the swine flu cases in Mexico until late last week.

From this afternoon’s briefing at DHS:

QUESTION: Can you tell us, Madam Secretary -- and perhaps Mr. Brennan, as well -- a little bit about when the United States government first became sort of fully aware of, you know, these events in Mexico [...]

[JANET] NAPOLITANO: Sure. John, do you want to -- OK.

BRENNAN: The first instances of the influenza down in -- in Mexico were the end of last week. In terms of confirmation, it was like Thursday or Friday of last week. [April 23 and 24]. So the Mexican health authorities knew they had a health issue. And, therefore, they sent the samples to both the Canadian labs, as well as to the CDC. And so the confirmation that it was swine flu was last week. [...]
Those replies are precious. They avoid the key issue of when the U.S. government was apprised of an unusual flu outbreak Mexico and the Canadian government's intelligent actions in response.

Yet evidentially Napolitano and Brennan were unaware during the briefing that Veratect Corporation's lead scientist, Dr James Wilson, had gone public with Veratect's timeline, which is published on Wilson's website, Biosurveillance; it details Veratect's strenuous efforts to impress on U.S. public health officials and the World Health Organization the urgency of the flu epidemic unfolding in Mexico.

If Rahm Emanuel didn't know earlier about Veratect I'm sure he found out this morning when he read The Washington Post:
[...] News of an outbreak of severe respiratory illness in Mexico burst into public consciousness last Friday, April 24.

That was 18 days after public health authorities there started looking into unusual cases of pneumonia in their country, eight days after Mexican authorities notified the World Health Organization of the growing outbreak and four days after the events came to the full attention of the Centers for Disease Control and Prevention in Atlanta.

Officials involved in pandemic preparedness at the U.S. Department of Health and Human Services, which oversees the CDC, did not learn of the Mexican outbreak until the day the rest of the world did, April 24. They did know, however, that the CDC was investigating six rare cases of swine influenza in California and Texas.

As Mexican health authorities were finding cases of unusual illness, they at least once officially notified the WHO's regional office in Washington, the Pan American Health Organization (PAHO), of a possibly brewing epidemic.

People in the WHO's Geneva headquarters also received several urgent warnings from a biosurveillance firm, Veratect, based in Kirkland, Wash.

The delay in making the global health community aware happened despite the adoption in 2005 of international health regulations requiring nations to report to the WHO within 24 hours any disease outbreak that is serious, unusual, at risk of spreading internationally or potentially disruptive of trade.

By the time international authorities became fully aware of the outbreak, there were about 800 cases and at least 50 deaths, and the virus was unknowingly being carried into other countries.

What seems apparent is that the world health community's newly rebuilt, well-oiled -- but never used -- mechanism for warning the world about pandemics may have given nations far less lead time than intended.

"After all this work on flu surveillance and setting up a reporting system and then this -- perhaps this isn't the best example of how it's supposed to work," said a highly placed health official in the Obama administration who was not authorized to speak on the record.

After the balky start, however, the WHO's pandemic response system is running well.[...](1)
That's a very nice way of putting it all, but there are passages in the Veratect timeline that are damning.

Before I provide examples: you can abandon the forlorn hope that Veratect's emails and phone calls simply got misplaced or relegated to the low-priority inbox.

Veratect is to pandemic what NORAD is to missiles. It's an early warning system that, working from open-source reports and utilizing an extensive global network of contacts, locates and tracks disease outbreaks around the world -- then warns governments of any disease pattern that might indicate the start of a pandemic. So it's a fair guess that Veratect alerts are immediately opened by everyone on the email list. From the (updated) timeline (emphasis mine):
April 20

Veratect was urgently asked to provide access to the VeraSight Global platform on 20 April by a client in the US public health community, and indicated they had received word from their counterparts in Canada that Mexican authorities had requested support. This client speculated whether notification of all southern U.S. border states’ public health authorities should be done and were confused as to why the CDC had not issued an advisory. Veratect contacted the CDC Emergency Operations Center to sensitize them about the situation in Mexico. CDC indicated they were already dealing with the crisis of recently detected H1N1 swine influenza in California and possibly Texas.

April 21


Veratect sensitized the International Federation of Red Cross who in turn requested broader access be provided to the Pan-American Disaster Response Unit (PADRU). Veratect moved to notify several US state and local public health authorities, providing the caveat the situation in Mexico remained unclear due to pending laboratory results. Veratect reached out to World Health Organization (WHO) operations, informing them the Veratect team was on an alert posture and available for situational awareness support. They indicated they and their subordinate, the Pan American Health Organization (PAHO) were now aware of the situation but had no further information. Veratect also extended contact to the British Columbia Center for Disease Control and offered assistance in tracking the events in Mexico. All contacts indicated laboratory results were pending.


Veratect also reported the National Ministry of Health issued a health alert due to a significant increase in influenza cases during the spring season in Mexico.

Officials indicated that there have been 14 influenza outbreaks throughout the country. The most heavily affected states are Baja California, Chihuahua, Distrito Federal (Mexico City), Hidalgo, Tlaxcala, and Veracruz. Local case counts were not provided.

April 22

Veratect also reported the Mexican Ministry of Health indicated that an "unusual" outbreak of laboratory-confirmed influenza caused five deaths from 17-19 April 2009 in Mexico City, Mexico. The deaths occurred at the following three hospitals: el Hospital de la Secretaría de Salud (2), el Institute Nacional de Enfermedades Respiratorias (2), and el Hospital Ángeles del Pedregal (1). According to unofficial sources, the fatal case count was higher than that provided by officials. There were currently 120 influenza cases hospitalized throughout Mexico City. National health officials indicated that influenza vaccines were sold out in Mexico City and that they were attempting to acquire additional supplies of the vaccine.

At this point, the Mexican Health Secretary reportedly stated there was an influenza epidemic in Mexico City and throughout the rest of the county. In response to the cases, the official stated health authorities would launch a public awareness and vaccination campaigns.

Sources reported a total of 20 fatal cases of influenza throughout Mexico over the disputed timeframe. The other cases were located in San Luis Potosí (4), Baja California (2), and Oaxaca (1). The Director of Epidemiology at the National Center for Epidemiological Surveillance and Disease Control characterized the outbreak as "quite unusual."

No information was provided indicating that the strain of influenza itself was unusual. Rather, several sources indicated that it was "unusual" to record this many fatal influenza cases during this time of year. Influenza cases normally peak from October to February, while these cases had occurred during Mexico’s spring season.

Canada announced a national alert for travelers returning from Mexico with respiratory disease, beginning a campaign of public media announcements. Potentially ill contacts were identified returning from Mexico and isolated in Canada. [...]
Why didn't the U.S. government issue a similar alert at the same time? Why didn't State post a travel advisory or at least an alert at the time?

If they answer that such actions are not the U.S. government's traditional way of handling things, particularly regarding a neighboring country -- traditions should have gone out the window after the SARS outbreak.

If they answer that they were waiting for WHO to raise the pandemic alert level to 4 -- here we come to the most interesting part of the story:

If it was left up to WHO we might be still be waiting for them to raise the alert level. But in this crisis WHO has been the caboose and Veratect has been the engine. The general public is the last to know, but Veratect had already raised the pandemic threat level by treating the outbreak from the viewpoint of 'operational reality.' On April 26 James Wilson discussed that reality in a post at Biosurveillance:
Are the WHO Pandemic Phases and the CDC Pandemic Severity Index Relevant in the Operational Environment?

WHO has recently announced they do not have enough information to change current WHO phase of pandemic alert [...]

At this point, it is safe to say the world has moved on with heightened surveillance, response actions, and additional preparations regardless.

DHHS and CDC also have the so-called Pandemic Severity Index, which of course is not in use at the moment because no one wants to utter the dreaded word, “pandemic”.

The PSI has not been publicly used since the beginning of the current swine flu crisis. The reason is semantics - the word “pandemic” has not been embraced yet by the public health community.

And yet, the world clearly has embraced the fact we have an emergency to deal with. [...]
The next day WHO in effect rubber-stamped the Veratect warnings by raising the pandemic threat level to 4. They did the same when they raised the threat level to 5.

WHO really had no choice but to raise the threat level -- and the U.S. government had no choice but to bring up the rear. The global network of physicians and scientists who were plugged into BIWAC -- the Biosurveillance Indication and Warning Analysis Community, which Wilson co-founded -- raced ahead of the lumbering gait of bureaucracy and drove the response to the threat of an emerging disease.

In his post last night at Biosurveillance Wilson found kind words for WHO and the CDC. But he made clear that locating the earliest signs of public health threats requires a particular kind of institutional 'culture' that's quite different from the one generated by a large complex bureaucracy. He also stressed that while the two cultures can be complimentary, they represent -- or should represent -- a division of labor:
[...] The best (albeit imperfect) analogy I use for what our team does versus what public health does is the US National Weather Service versus FEMA.

The National Weather Service focuses its efforts solely on the detection and warning function, whereas FEMA is more concerned with what happens when and after the hurricane hits. The culture of early warning, and the people drawn to that kind of work, are very different from the response culture of FEMA.[...]
I hope you find time to read the entire essay (which is short), because Wilson's observations are at the heart of debates about many areas of endeavor. Fans of Zenpundit will recognize in Wilson's argument the tension between the most creative military minds of today and the military bureaucracy. Yet Wilson misses the mark when he tries to rationalize the ways of bureaucracy:
CDC, PAHO, and WHO must maintain credibility at all times with the public. This is non-negotiable or situational control may be lost. During a pandemic, it would be a disaster for public health to lose credibility. Therefore, they must be sure, confident, and push diagnostic resolution to the maximum degree possible. The downside is that process takes time.
The biggest downside is that bureaucracy is always under the thumb of a political class, which is taffy in the hands of competing special interests and government agendas. The upshot, too often, is screw-ups on a horrific scale. This makes it hard for bureaucracies to maintain credibility at any time with the public, much less all the time.

This brings me to the question: What was Argus doing while Veratect was moving heaven and earth to warn agencies, including the CDC, about the emerging disease threat in Mexico?

What is Argus?
Situated on the tree-lined campus of Georgetown University’s Medical Center in Washington, D.C., is Project Argus, one of the nation’s premier biosurveillance systems for detecting and tracking early indicators of, and warnings about, international biological events. Argus exemplifies real-time global health engagement taking place between academia and federal government agencies tasked with the critical mission of protecting domestic and global public health, and national security.

Argus’ primary function is to alert CDC, and other users, to biological events that may require a public health response. The system monitors media and other electronic sources at the local level around the globe for three types of indicators: reports of disease outbreaks, potential environmental triggers, and social disruption.

Since it began operations in July 2007, Argus has logged more than 30,000 biological events involving pathogens such as avian influenza, Ebola virus, cholera, and other unusual pathogens that have caused varying states of social disruption throughout the world. Argus currently accesses more than 1 million pieces of information daily, and produces, on average, 200 reports per day. Argus covers all the countries officially recognized by the United States. Analysts are collectively fluent in 36 languages.[...]
Would the fluency include Spanish, I wonder?

Taking a shot in the dark, it might be that Argus hasn't been quite the same place since Dr. Wilson left. From his biography at Biosurveillance:
James M. Wilson V, MD [...] is currently the Chief Technical Officer and Chief Scientist of the Veratect Corporation in Seattle, Washington. He was the Principal Investigator of Project Argus, Chief of the Argus Research Operations Center, and Division Head of Integrated Biodefense at the Imaging Science and Information Systems Center, Georgetown University. [...]
I can understand that Dr Wilson would want to maintain a collegial tone with the CDC and DHS (which he also worked for), but let's dispense with the crumpets and croquet, shall we? The U.S. government screwed up by ignoring Veratect's early warnings and the example set by Canada in dealing with the virus.

As for the CDC's fancy biosurveillance agency and its fluency in 36 languages --

Reading through the CDC description of Argus and the US interagency cooperation to deal with health threats around the world -- (E.g., "The strong USG agency ties developed through Argus and the BIWAC helped to identify laboratory collection difficulties in response to a recent outbreak in Tbilisi, Georgia, of African swine fever (ASF), a highly contagious disease affecting pigs that, unchecked, can spread rapidly and cause crippling economic consequences.") -- I was struck by the huge amount of attention that CDC lavishes on far-flung parts of the globe. Yet somehow they were slow to react to a health crisis on America's doorstep.

1) The Washington Post: System Set Up After SARS Epidemic Was Slow to Alert Global Authorities; David Brown, April 30

2) The Washington Post: U.S. Slow to Learn of Mexico Flu; David Brown, April 26

No comments: