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April 30, 2009
Exclusive: Swine Flu – Black Death, False Alarm or Mother Nature’s Bioweapon? (Part One of Two)
“The single greatest threat to mans continued existence on earth is the virus.” – Dr. Joshua Lederberg, Nobel Laureate
So, will there be life after mankind? There was life before us, so the short answer is yes. But don’t plan on leaving terra firma just yet. Swine flu (Swine influenza A/H1N1 or Swine origin influenza A/H1N1, SOI A/H1N1)) may or may not be “the big one,” but let’s not let our guard down regardless of the outcome. Let’s take the threat for what it is – a potentially deadly outbreak. But the world has them all the time.
The 1,000 or so suspected cases in Mexico that have been reported must be tempered by the actual number of confirmed cases – significantly less than that number. That of course doesn’t mean the others weren’t infected. But the U.S. has less than 100 confirmed cases of swine flu.
So why are we NOW worried about influenza? Every year 36,000 people die in the United States as a result of seasonal influenza. Swine flu is contagious – so is seasonal flu. Yet no one makes an issue of it. Worldwide it is likely 500,000 die annually from influenza. And yes, there are pockets of outbreaks across the country and globe. Again….to date, one person out of 91 known, confirmed cases has died in the U.S. from swine flu. So why are we worried about another strain of influenza, notably one that remains treatable by readily available antiviral medications? Especially when you consider at least some of the circulating influenza viruses this season demonstrated some resistance to one of our most valuable antiviral medications?
It’s not like we don’t we have a lot of serious things to worry about? Our military and civilian labs located on U.S. soil that, without government guidance, cannot seem to secure some of the dangerous pathogens housed therein? Or lack of surge capacity in U.S. hospitals? How about health care facilities that don’t have preparedness plans or when they do, they are rarely practiced? Perhaps knowing that numerous EMS services have selected to focus on areas other than pandemic response planning? USAMRIID not quite sure if it had lost dangerous virus samples? Maybe it’s the persistent problems with delivering countermeasures, poor interoperability or communications shortfalls that continue to plague TOPOFF and other federal or state drills? And that is the short list! Or perhaps a total inability to close off the US- Mexican border, even if the government was inclined to do so.
Why are we worried? Influenza pandemics have been responsible for millions of deaths over a short period of time. There are numerous flu strains “out there” – and most can cause some form of illness, once in a while a novel strain emerges, and is capable of creating havoc. Is this version of swine flu that novel strain or just another novel strain in a long list of low grade nasty bug?
For right now, the critical issue we face is how we prepare and respond that matters. And therein rests the angels in the details. Information is the best cure for fear. So this article will discuss what we know and what we don’t yet have answers to. Additionally, an introduction to influenza and pandemics as well as overview of the threats we face from biologicals will be provided followed by some suggestions how to stay safer and healthier during these challenging times and other solutions to our vulnerabilities.
WHAT WE KNOW
As of April 29th, the World Health Organization (WHO) has raised the pandemic alert threat level for SOI A/H1N1 to a 5 signifying a pandemic is imminent.
This is the second time in a week that the WHO has raised its pandemic alert level, which ranges from phase 1 – a low risk for pandemic to phase 6 which indicates the world is involved in a full-blown pandemic under way.
WHO Pandemic Levels
Here is a quick look at the WHO's pandemic alert phases:
- Phase 1: A virus in animals has caused no known infections in humans.
- Phase 2: An animal flu virus has caused infection in humans.
- Phase 3: Sporadic cases or small clusters of disease occur in humans. Human-to-human transmission, if any, is insufficient to cause community-level outbreaks.
- Phase 4: The risk for a pandemic is greatly increased but not certain. The disease-causing virus is able to cause community-level outbreaks.
- Phase 5: Still not a pandemic, but spread of disease between humans is occurring in more than one country of one WHO region.
- Phase 6: This is the pandemic level. Community-level outbreaks are in at least one additional country in a different WHO region from phase 5. A global pandemic is under way.
It is important to recognize that the WHO phase designation refers more to virus spread than the severity or lack there of associated with the resulting disease.
Echoing that thought, CDC Acting Director Richard Besser, MD, said that the U.S. is at a "pre-pandemic" level and that it matters less what the situation is called than what's being done about it, and that the U.S. is taking "aggressive" action to limit swine flu's impact on human health.
According to Mexico’s Health Secretary Jose Angel Cordova, as of late Sunday the number of suspected swine flu cases in Mexico had climbed to over 1,600, with over 150 reported dead as of Tuesday. According to the World Health Organization, the number of laboratory confirmed cases in Mexico is 26, with seven deaths. Nine countries (Austria, Canada, Spain, United Kingdom, New Zealand, Israel, Germany, U.S., Mexico) are reporting confirmed cases; only the US and Mexico report deaths. As of this writing, 91 people have been laboratory confirmed as infected by swine flu in the U.S. And among them, one person has died and several have been hospitalized. The median age of those infected in the U.S. is 16 years with a range of approximately 2– 81 years. The distribution is roughly equal between genders. The first fatality from swine flu in the U.S. was an almost 2 year old child in Texas who had underlying health issues. Again, as a caveat, since we still don’t have our arms fully wrapped around this outbreak and won’t until it continues to play out and more information is derived from clinical, laboratory and epidemiological investigation, never the less it is worth repeating that in typical seasonal influenza, the very old and very young usually experience the brunt of the disease. In novel and highly pathogenic influenza viruses such as avian flu, those normally minimally affected by seasonal flu – 20-50 year olds, in fact get hit dramatically.
According to the Centers for Disease Control and Prevention (CDC) the clinical illness associated with this outbreak of SOI A/N1N1 are consistent with a seasonal influenza-like illness. Signs and symptoms include fever and respiratory tract illness (cough, sore throat, runny nose), headache, muscle aches - and some cases have had vomiting and diarrhea. These cases had an onset of illness during late March to mid-April 2009. However, cases of severe respiratory disease consistent with a pneumonia illness, including fatal outcomes, have been reported in Mexico. Patients with chronic medical conditions such as cardiac, immunological or pulmoary disease can have their illness worsened by swine flu.
The current SOI A H1N1 virus is a novel influenza A virus that has not been previously identified in North America. Human-to-human transmission (contagion) is occurring.
Persons with swine influenza A (H1N1) virus infection should be considered potentially contagious for up to seven days following illness onset. Persons who continue to be ill longer than seven days after illness onset should be considered potentially contagious until symptoms have resolved. Children, especially younger children, might potentially be contagious for longer periods.
As of April 29, 2009, the CDC and FDA have approved the use of RT PCR testing which should speed things up a bit at the clinical end. DHS has released millions of doses of Oseltamivir (Tamiflu) and Zanamavir (Relenza) as effective treatment for swine influenza. Administered early it is likely these medications will reduce the severity of illness.
WHAT WE DON’T KNOW… YET
First and critically important – what is the vaccination status of people infected by SOI A/H1N1? How many of the 91 victims with confirmed swine influenza infection received the annual flu shot? Information is still being gathered. This is important as it might give an insight into the potential for protection against swine with the currently available flu vaccines. Otherwise a new vaccine will have to be developed and distributed. Based upon current influenza vaccine methodologies, producing sufficient quantities could be time consuming. Ideally we already have one on the shelf. To date, this is an unknown. Nevertheless, if you haven’t received a flu shot…GET ONE! Flu vaccine 2009 is NOT the problem child swine flu vaccine of 1976. You CANNOT get the flu from 2009 flu shots!
Second, just how virulent and dangerous is this strain of swine flu? Is it the next avian flu – capable of direct lower respiratory tract-pulmonary damage, or a more aggressive form of the relatively mild swine flu that, like most seasonal flus which that affect the upper respiratory tract and causes a less severe form of illness? Most of the patients being seen and confirmed with SOI A/H1N1 in the U.S. have been relatively mild. Is this the true picture? If this strain of swine flu is in fact an emerging pathogen, the question arises – which picture is truly representative of its power to sicken – Mexico where people presenting for care are quite ill or dying, or the U.S. where illness is mild? Or are they the same but we’re seeing different points on the same continuum? Manifestations based upon quite different health care systems and national resources?
According to WHO Director – General Margaret Chan, "the biggest question is, how severe will the pandemic be?" At a news conference on April 29, 2009, in Geneva. Chan continued, "We do not have all the answers right now, but we will get them." Chan said the swine flu situation is changing rapidly and the swine flu virus is still "poorly understood."
Until additional laboratory, pathology and epidemiologic data are obtained, these questions will remain unanswered. But for the interim, we know social distancing, travel and crowd precautions can reduce risk. More on that later.
It is important to recognize that some of the patients suspected of having swine flu in Mexico may be infected with other endemic illnesses including metapneumovirus, which can also cause pneumonia and severe illness.
Consider the possibility this strain of swine flu is generally benign but capable of causing severe illness in a small percentage of victims. In Mexico over 1,600 may have been affected; 150 are dead. Given the poverty level, limited resources and lack of widely available/affordable care – perhaps many within the country are sick but with mild illness, same as here, only they haven’t been counted or tested. Thus only the most sick are presenting for medical care in Mexico and therefore skewing the perception that it is a more deadly pathogen by virtue of the numbers being evaluated at health care facilities. Whereas in the U.S. those who have the mild symptoms are going to a clinic right away and thus with the limited number of people infected and the quick access to care, we are seeing the truer picture that generally this is a more mild infection. In the U.S. as of this week, those suspected of swine flu illness are likely to be tested. Then there’s the medication factor; the sooner you get to a U.S. clinic, the more likely you are to receive antiviral medications which can prevent the progression of the illness and thus reduce the potential for pneumonia and other severe symptoms that are occurring in Mexico. Just one thought! Early information from Mexico where health authorities are now being more aggressive in their providing antiviral medications; an effective strategy to reduce severity of illness.
We are still too early into the outbreak to have all the questions answered. But the questions do need to be asked. And our officials need to be held accountable – for the good job they did, they warrant praise, and for the mistakes they have made, an exhortation to remedy the challenges before the next outbreak. Because there will be others.
Clearly one of the reasons for concern is this is considered to be a novel strain of swine flu. Any time a new pathogen is discovered, especially one that causes human illness or more dramatic symptoms than other similar strains do, gets attention and warrants concern. Global concern is justified. And though some think the media hype has outrun the science, in actuality it has been largely restrained; clearly the MSM has made an effort to report facts more than worst case supposition – to their credit.
And the concern is also justified if for no other reason than it reminds us how fragile our health security is, the power of infectious diseases to disrupt our economy and our daily lives as well as the potential to take our life without respect for race, religion or wealth. Outbreaks tell us how far we have yet to go to ensure a long term and sustainable strategy against pandemics. Preparedness is not an event or activity; it is a process; one that can provide an adequate response to a deadly outbreak.
OVERVIEW THROUGH THE PREPAREDNESS PRISM
Since 1918 when millions died from a deadly strain of flu virus, and as a result of the subsequent global epidemics (pandemics) which also caused significant loss of life and social disruption, medical experts, emergency planners, political leaders and public health officials have been vigilant for the next major influenza event. It has never been about “if” another strain capable of causing a global pandemic similar to 1918 will occur, but “when.” And as you will see, tracking viruses, predicting or even identifying the next “killer strain,” containing it and appropriately responding in live time are complicated issues and result in the dynamic interplay of civic leaders, the medical, homeland security, preparedness communities at the federal, state and local levels and the cooperation of an informed citizenry. Providing the appropriate risk communications message is the determinant in how successful our leaders walk the razor’s edge between alerting versus alarming the public; it is a challenge. And a worthwhile one; the ability to contain an outbreak rests upon the collaboration between the public and the medical/response communities.
As we’ll see momentarily, it is a daunting challenge to prepare for, attempt to contain and ultimately provide the best care in live time to minimize the effect of an infectious disease that can be highly effective at rapid person to person transmission. There are numerous points along the preparedness continuum that prior planning allows you to have control over the results.
Unfortunately four wild cards are always at play in any preparedness situation.
First – Our assumptions were wrong! We just didn’t plan correctly.
Second - Murphy’s Law. No way around it. Things can unravel in spite of our best laid plans. The unexpected can happen. And while “chance favors the prepared mind,” as offered by none other than the great infection fighter Dr. Louis Pasteur, never the less, weird things can occur. Accidents happen. Planes filled with countermeasures can crash. Weather can occur that spoil the plans.
Third – The limits of our knowledge. Planning is based upon what we know and what we think we won’t know. But in the end, even with the best protocols and guidelines based upon the latest science, we may still have to adapt on the fly.
Fourth – Dependence upon entities for whom we have little or no control. The United States is one nation among many. We are blessed with both strong central and state governments, some of the best health care in the world – clearly in terms of accessibility and quality even if not affordability, and significant resources that most nations can only aspire to. Other nations such as Mexico are impoverished by comparison; their medical and public health infrastructure, citizen ability to afford care for less than severe illness, and the crowded conditions – in the cities and on the farms near livestock, provide the perfect situation to allow what could be a containable outbreak to develop into the cause of a global outbreak. And that is what has happened with swine flu 2009.
This persistent vulnerability – the interdependence of nations – remains problematic when an outbreak occurs. Though homeland security and medical issues should not be politicized given the stakes are high and the potential for lives lost can be great, it is naïve to think countries won’t put their interests before those of others. And therein rests one of our greatest challenges in pandemic preparedness.
Consider what catalyzed pandemic preparedness – a novel strain of highly pathogenic (nasty) avian influenza from parts of China and Hong Kong. Twice it gave the world a wakeup call. The first time in 1997/1998 when cases of severe respiratory illnesses of unknown cause; it was then determined that a new strain of avian flu – one with a greater capacity to cause death than more benign strains – emerged. Large numbers of poultry were also sickened and dying. The strategy to contain a human epidemic – isolate the sick, aggressively treat the ill, provide preventive measures to those who have been in proximity with them, identify the source, and limit contact to the area. It was determined close proximity to sick birds was the major risk factor. The solution? Kill the flocks. Well if you are poor and need those birds to feed your family, what do you do? Do you voluntarily kill your livestock? With proactive and effective political leadership…yes! Why? Because the government will pay you promptly for the sake of the community to do it. In the late 1990s, the United Kingdom was in charge of Hong Kong and the farmers got paid. The outbreak was contained. But there was a changing of the guard in Hong Kong. Then in the early 21st century, another strain of avian emerged; same regions of China and Hong Kong. The Chinese tried to hide the problem by feeding poultry with a class of antiviral medications in the hope of nobody would notice. Killing the flocks was not the first strategy nor was alerting world health agencies. Would it surprise anyone that “strategy” didn’t work?
First, quelle surprise:strains of avian flu developed resistance to amantadine. When you consider there are effectively only two classes of antivirals with proven effectiveness against influenza and you have just taken one class off the table with the realization that amantadine is not effective, you have potentially altered the balance of power. Fortunately the neuraminidase class is still effective; but resistance to Oseltamivir (Tamiflu) has developed in certain strains.
As avian influenza progressed through 2005 and 2006 a few things gave governments reason for concern. First it was spreading faster among a wide array of bird flocks than containment strategies could handle. When all was said and done, somewhere between 100 million and 200 million birds died from avian flu. A new strain emerged that was increasingly aggressive. Then a phenomenon was observed that here to fore was considered completely unlikely for avian influenza – person to person spread. While it never propagated, instead stopping after infecting only close contacts, nevertheless the chilling reality that this bug could “learn” to become contagious through a variety of adaptive events, prompted agencies worldwide to create pandemic preparedness plans and stockpile essential equipment and countermeasures. This also led to some promising vaccines and new technologies to fast track immunizations. Some have been FDA approved and others remain in clinical trials.
As an aside, avian influenza continues to be a human pathogen; so far >20 people have been infected in 2009.
INFLUENZA VIRUSES AND PANDEMICS – AN INTRODUCTION
Influenza Viruses
You may have seen the notation H1N1 next to the name of the influenza virus “swine flu H1N1.” There are lots of flu bugs around, and each has a name and number – some are H3N2, H5 N1 and so forth. I’ll spare you the microbiology lesson. However, a crash course in flu 101 is worthwhile.
The term “influenza” describes an acute viral disease of the respiratory tract often referred to as “the flu” caused by viruses belonging to the orthomyxovirus family, which includes the genera of influenza virus A, B, and C as defined by the antigenicity of the nucleocapsid and matrix proteins. Generally, A viruses are associated with more severe human illness, epidemics, and pandemics. Influenza A virus is a negative sense, single-stranded RNA virus, with an 8-segment genome that encodes for 10 proteins. They are further classified or sub-typed based on two surface proteins: haemagglutinin (H) which attaches the viral particle to the host cell for cell entry, and neuraminidase (N) which facilitates the spread of progeny virus. It is the latter which is a target for the class of antiviral therapy referred to as neuraminidase inhibitors. There are 16 H and 9 N subtypes making up all the subtypes of influenza A by various combinations.
Think of flu viruses as if they were a hand of black jack played like “Fish”; two cards dealt to you. One card comes from one of two decks – the H deck and the N deck. Since cards can be shuffled, you can get different hands. Then when you play, you can swap a card in your hand with another player – say one of you is a bird, another a pig and a third player a person. When the cards are strong – think nasty pathogen. When they aren’t – think low grade illness. Of course there is more to the analogy – think of the inks on the cards as genetic material that can swap off between cards, too!
Because influenza has a segmented genome (two cards in the hand), shuffling of gene segments can occur if two different subtypes of influenza A virus co-infect the same cell. Conditions favorable for the emergence of antigenic shift have long been thought to involve humans living in proximity to farm animals, namely poultry and pigs. Pigs are susceptible to infection with both avian and mammalian virus. If a human influenza virus, such as H3N2, and an avian H5N1 virus co-infect a human or pig, it is possible a new virus H5N2 could emerge – a hybrid that could combine the high virulence of H5N1 with the efficiency of human to human transmission found in the “parent” human virus. Studies suggest that this reassortment of genetic material is what happened in the 1957 and 1968 pandemics. This reassortment could also be accomplished in a laboratory for bioterrorism. When the genetics of a bug are novel, it becomes difficult to predict who aggressive or the range of capabilities the virus has – ability for person to person transmission, medication resistance, etc. Sometimes within the strain it can evolve. Avian flu started out as low pathogenic and evolved to become a highly pathogenic (nasty) virus.
Pandemics
A pandemic is generally considered to be a global outbreak – a multi-continent epidemic. There have been three major influenza pandemics in the 20th century: the “Spanish Flu” (Influenza H1N1) in 1918, the “Asian Flu” (H2N2) in 1957, and the “Hong Kong Flu” (H3N2) in 1968. The latter two pandemics resulted in estimated worldwide deaths of 2 million in 1957 and 1 million in 1968. Although estimates vary on the total number of deaths credited with these pandemics, most agree that at least 50 million died from the Spanish Flu between 1918 and 1919, with deaths predominantly occurring within a few days of infection. And, of all the deaths from the 1918 pandemic, over half the dead were young, healthy adults, an uncommon phenomenon with seasonal flu illness. Scientists concluded that origins of the strains of influenza virus causing the 3 pandemics were viruses containing combinations of genes from both a human influenza virus and an avian influenza virus.
As an aside, in this era of bioterrorism preparedness, it is important to note that the reassortment of influenza genes could be employed for the creation of biological weapons. Avian influenza was the catalyst for much of our pandemic preparedness as it represented the most likely pathogen to cause the next pandemic, according to the World Health Organization (WHO) and Centers for Disease Control (CDC) back in 2004. WHO issued a report in December 2004 in which the threat of an influenza pandemic occurring in the near future has greater likelihood with the recent appearance and wide spread of avian influenza H5N1.
Swine Influenza (swine flu) is a respiratory disease caused by type A influenza viruses (flu viruses) that result in regular outbreaks in pigs. People usually do not normally get swine flu, but human infections can and do happen. The exact magnitude of people infected by swine flu viruses is unknown. There are usually two patterns of symptoms of swine flu in humans; historically the most common are typically low-grade, respiratory in nature, with fever, cough, runny nose, and body aches. Sometimes vomiting and diarrhea also occur. Another least common pattern resembles pneumonia; shortness of breath and higher fevers can occur usually in the context of a more rapid progression of symptoms
Avian flu: Swine flu – what’s the difference?
Avian flu was dramatically different from typical influenza in that the former attacked the lungs; the latter is more an infection of the upper respiratory tract. Swine flu is providing a picture that seems to straddle both types of infections. Until more clinical information is available, we should treat it as a wild dog until we know it is a fluffy Maltese.
HOW CAN A PATHOGEN CAUSE A PANDEMIC?
Three factors must be present in order for the emergence of a new influenza virus to result in an influenza pandemic:
- People have little or no immunity for the virus
- The virus spreads readily from person to person
- No vaccine is readily available.
CURRENT STATE OF AFFAIRS
Some good news: President Obama and Secretary Napolitano should send off a thank you note to their respective predecessors, President Bush and Secretary Chertoff. The plans we have in place and the countermeasures available for the exigencies we face – terrorism, pandemics, natural disasters were born out of lessons learned, sometimes the hard way: 9/11, avian influenza, Katrina, floods. While once could argue the plans need work – and all plans MUST be revised, the current administration could pull from the shelf a good starting point.
For example when DHS says it will release a portion of the antiviral medications from the strategic stockpile – that’s terrific…it is reassuring for the public to know that we have the medications and can make them available. But that is not the same thing as sending a flying Walgreens or CVS to the site. Someone has to unload the plane, bring the countermeasures safely to the event. Easier said than done! In virtually all of the major city or national drills including TOPOFF which involves the top officials – interoperability, interagency communications and timely delivery of countermeasures during a crisis were the first casualties of the exercises. By releasing these materials early when a full blown “cluster duck” has yet to occur, we can work out the kinks in the system. When it hits the fan that is not the time to exchange business cards; federal-local familiarity usually comes during crisis; with a slow moving one each responder culture can use the time to enhance interoperability.
Most large public health departments will also tell you they do not yet have the security part of the puzzle yet solved in terms of protecting the medications or the sites where they have to be deployed. So the government gets good marks for early release; and got a break in the fact that there are not massive numbers of cases concentrated in selected regions going on simultaneously. When and if that happens locals will need more than meds; they will need equipment and lots of it. And when that happens, the ongoing problems above mentioned, which have yet to be sorted out, will manifest. They need to be remedied now…swine flu has opened the window into a real albeit easy response…swine flu in the US is traveling fast enough to concern us but slow enough to let us study our response –the good and the bad. Let’s not lose this opportunity for an honest evaluation which can lead to real time improvements. To have such persistent problems as mentioned above almost 8 years post 911; we can do better.
There are some ongoing kinks in the system:
Consider for the moment one of the most important components of our response infrastructure – emergency medical responders. Whereas much effort has been focused on hospital, public health, and government response to a influenza pandemic, two vital responder communities—the emergency medical services (EMS) professional (EMT and paramedic) and the private physician—remain somewhat disenfranchised. When 911 is called, most likely it will result in an ambulance being sent to an acutely ill victim In a recent online survey conducted by the Journal of Emergency Medical Services (JEMS) whose readers are medics, emergency physicians, and EMS administrators – were asked if their EMS agency had a plan for operations during a pandemic flu outbreak, including stockpiles of N-95 masks. Only 17% of total respondents answered “yes,” whereas the majority stated “no” because they were focusing on other planning initiatives. This relative lack of preparedness may reflect lack of funding, inadequate training, or disenfranchisement from public health efforts. All are readily repaired with some leadership.
EMS has a difficult job – they are the boots on the ground, the first responders who go into a crisis, like fire fighters, when others are running from it. We should provide them with the guidelines for pandemics and the funding to implement an enhanced response. Fact of 21st century life – interest goes where dollars flow.
When the government addresses a new threat– crisis management based upon quarterly reports and sound bites – are the usual modus operandi, whether 9/11, anthrax, pandemics. But this is not efficient. Government can no longer afford to toss money like a drunken sailor in the first two year aftermath of a crisis to “ramp up” or remedy vulnerabilities, then cancel initiatives in order to fund something else midstream in the development, preparedness phase. Yet that is precisely what happens. For example, after anthrax, hospitals started implementing preparedness planning, using initial funds that were start up at best, only to watch the dollars go elsewhere while the hospitals remain left trying to locate money to finish the job. This is not effective leadership from the top. Yet over and over again we see the same pattern in preparedness. Dollars, then eventually benchmarks how to spend them wisely – usually years after the initial funds have been spent will it dawn on folks….just what did that money buy us? Are we better prepared? And by what metrics?
Even when lots of money is tossed around, the same old recipients – public health, law enforcement and health care facilities gain the lions share. What about EMS, physicians and other health care providers?
It is also just as likely that a community clinician may be called on to diagnose the sentinel case of avian flu in the United States, reminiscent of the diagnosis of the index case of inhalation anthrax in 2001.2 Most scenarios describe a significant number of people becoming quite ill over a relatively short period of time. It is important to realize that a sick individual may precede such an outbreak, underscoring the critical importance of providing advanced training to physician in recognition or suspicion of emerging pathogens, given that early diagnosis can save a life and alert the medical community of a developing threat. In a global world, anything from deadly animals used for exotic pets to infectious diseases can be imported. Primary care clinicians should be aware of these risks and convey information about them to their patients.
Part Two will continue with a discussion of countermeasure and vaccine research.
FamilySecurityMatters.org Contributing Editor Dr. Robin McFee is a physician and medical toxicologist. An expert in WMD preparedness, she is a consultant to government agencies, corporations and the media. Dr. McFee is a member of the Global Terrorism, Political Instability and International Crime Council of ASIS International. She has authored numerous articles on terrorism, health care and preparedness, and coauthored two books: Toxico-Terrorism by McGraw Hill and The Handbook of Nuclear, Chemical and Biological Agents, published by Informa/CRC Press.
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