2007 Spring, Pg. 54. Why is Pandemic Influenza Different? Public Health Emergencies and Infectious Diseases.

AuthorBy Jose T. Montero, M.D.

New Hampshire Bar Journal


2007 Spring, Pg. 54.

Why is Pandemic Influenza Different? Public Health Emergencies and Infectious Diseases

New Hampshire Bar JournalSpring 2007, Volume 48, No. 1Health Care & the LawWhy is Pandemic Influenza Different? Public Health Emergencies and Infectious DiseasesBy Jose T. Montero, M.D.I. Introduction

Microbes live in every conceivable ecological niche on the planet and have inhabited the earth for many hundreds of millions of years. The vast majority of microbes are essential to human, animal and plant life. They are highly adaptable and occasionally a microbe is identified as a pathogen because it causes an acute infectious disease or triggers a pathway to chronic disease, including some cancers.

Infectious diseases continue to be a serious burden in developing and industrialized countries alike. Whether naturally occurring or intentionally inflicted, microbial agents can cause illness, disability or death. They can affect individuals or disrupt entire populations, economies and governments. In our highly interconnected "global village", one nation's problem can soon become every nation's problem as geographical and political boundaries offer trivial impediments to such threats.

Microbial threats emerge, reemerge, and persist. Some microbes cause newly recognized diseases in humans; others are previously know pathogens that are infecting new or larger population groups or spreading into new geographic areas. Within the last ten years, newly discovered infectious diseases have emerged in the United States and several of them made their way up to the New England region (e.g., hantavirus pulmonary syndrome from Sin Nombre virus, with a confirmed case in Vermont). During the same time, there has been a worldwide resurgence of long-recognized infectious diseases (e.g. malaria, cholera, dengue and tuberculosis). The United States has seen the importation of infectious diseases, such as West Nile Virus encephalitis, measles, multidrug-resistant tuberculosis and malaria, from immigrants, from U.S. residents returning from foreign destinations, and via products of international commerce.

The realization of just how quickly newly discovered infectious diseases can spread has heightened appreciation of the inherent dangers of microbial pathogens. Acquired immunodeficiency syndrome (AIDS) has become the fourth-leading cause of death worldwide in a mere 20 years since its discovery. Today, more than 40 million people are living with the infection from the human immunodeficiency virus (HIV), and 20 million people have died from AIDS. In just four years since West Nile virus was discovered in the Western Hemisphere, the virus has spread from its epicenter in New York to the 48 contiguous states infecting thousands and killing hundreds.

The emergence and spread of microbial threats are driven by a complex set of factors, the convergence of which can lead to consequences of disease much greater than any single factor might suggest, as described in the Institute of Medicine Report: "Microbial Threats to Health: Emergence, Detection and Response." Genetic and biological factors allow microbes to adapt and change, and can make humans more or less susceptible to infections. Changes in the physical environment can impact on the ecology of those animals capable of transmitting an infectious agent as well as those that can act as a host for such infectious agent without getting ill. The changes in the environment can modify the transmissibility of microbes, and the activities of humans that expose them to certain threats. Human behavior, both individual and collective, is perhaps the most complex factor in the emergence of disease. Emergence is especially complicated by social, political, and economic factors - including the development of mega-cities, the disruption of global ecosystems, the expansion of international travel and commerce, and poverty - which ensure that infectious diseases will continue to plague us. Today we also face the threats of intentionally introduced biological agents. The risks to humankind from the willful spread of highly virulent and contagious microbes are considerable, and we in the United States are preparing to defend ourselves with new vaccines, diagnostics, and therapeutics against the many microbes that might be used in a biological attack. We also are cognizant of the need to rebuild public health infrastructure locally and globally as an indispensable means of reacting to such threats.

The general public has a varied level of awareness on the complex mechanisms behind the emergency of infectious diseases threats and the risk that they represent to us as individuals or to the community at large. Today in the US, and especially in NH, infectious diseases are not the main threat to our well-being. A mix of factors including socio-economical situations (high average income, high level of education, and other demographic factors), well-respected public health strategies (availability of universal vaccination for children), general improvements in quality of life (potable water, sewage, general sanitation, food availability, etc) are making the threats of epidemics a remote risk.

In New Hampshire, the Department of Health and Human Services (DHHS) is the entity responsible for developing the programs and implementing the policies and procedures that will keep the threats of infectious diseases at bay. With the exception of Manchester and Nashua (the only cities with full service local health departments), all core public health activities are shouldered by DHHS. There are several statues and rules that govern the day-to-day activities and responses for infectious diseases at DHHS. There is a list of conditions that must be reported to the department because they pose a threat to the public health. Upon report of one of these conditions (infectious diseases and their causative agents), the DHHS communicable disease groups spring into action. These actions may include:

Communicating with the stricken patient's health care providers to discuss the diagnosis and treatment approach,

Contacting the patient to determine the possible source of infection, to discuss communicability, incubation period, need for isolation and whether anyone else may have been infected. Determining who has been exposed and has a high risk of developing the condition is one of the core actions of public health, since finding these potential victims of the condition and providing recommendations for prophylaxis or treatment will prevent further spread of disease.

Implementing community-based pharmacological and non-pharmacological containment measures. Depending on the condition, this may be limited education on general hygiene; establishing a clinic for distribution of antibiotics to thousands of school students (as was done in the Keene area in response to bacterial meningitis in a school); immunizing thousands of patrons from food establishments (as was done in the Derry area after a possible exposure to hepatitis A); and recommendations for environmental measures that spread across city borders (like those necessary for control of West Nile virus or Eastern Equine Encephalitis virus).

This approach may have been adequate for individual threats or clusters of illness as in the examples cited above. But our world has changed and events can now rapidly overwhelm the limited response capacity of our centralized system. These limitations were evident during the anthrax attacks of 2001 and the resulting community fears around "white powders." Even though DHHS responded properly, it was clear to us that, for statewide events, our approach and staffing patterns were a great limitation. Because of those events, the Division of Public Health Services developed different policies and plans that would lead to an improved, more sustained response. But it was clear to us that some situations were going to be far beyond even our improved response capacity.

Pandemics - outbreaks of diseases that occur over wide geographic areas (continents, etc)affecting high proportions of the population - are events that will quickly overwhelm our response capacity and require all elements of government and society at large to participate in the response because no single group will be able to respond properly on its own. The media is quick to highlight the occurrence of several infectious diseases and some times our rapid response to them. Our anxious modern society expects a rapid response by the government - actually demands it - and demands an immediate resolution of perceived external health threats, even where there is no need for such a wide response. Recent local examples can be found in the management of incredibly complex individual cases of tuberculosis, vaccine-preventable diseases spreading through sport events, or the threat posed by arboviral illness (such as Eastern Equine Encephalitis). Where the risk occurs across jurisdictions, a different approach is called for. The response is no longer the traditional individual public health interaction to educate and raise awareness of risky behaviors, or encounters with the involved health care providers, sealed with a magical prescription that will resolve the situation and protect us and our loved ones.

Instead, these situations require that we improve the partnerships between the public health departments and the health care system and expand it to a wider public health...

To continue reading

Request your trial

VLEX uses login cookies to provide you with a better browsing experience. If you click on 'Accept' or continue browsing this site we consider that you accept our cookie policy. ACCEPT