Europe, air travel and the plague

Secretary for Homeland Security Michael Chertoff made news the other day when he proclaimed the next terrorist attack against the United States could originate in Europe.

The head of US Homeland Security Michael Chertoff said in an interview with the BBC that there would soon be stricter security checks on people wishing to fly to the USA from the EU. Chertoff said that the planned tightening of security was due to concerns that terrorists "were increasingly looking to Europe both as a target and as a platform for terrorist attacks." He had "watched the rise of home-grown terrorism in Europe", referring in particular to the bombings in Madrid and London as well as the attempted bombings in Germany.

In a way, this should not come as a surprise as Europe is no more immune to disenfranchised individuals then we are. Ethnic divisions between the Walloons and Flemish, for example, came to forefront recently as an interim government was formed in Belgium. Some viewed this as an affirmation of the European Union that Belgium did not fall into immediate collapse. What it also shows is despite the apparent homogeny of the European Union old ethnic divisions still exist and could be the basis for a terrorist group to find new recruits. The Basques have taken exception to policies of both the governments of Spain and Portugal for decades. Kosovo has declared independence from Serbia potentially igniting new conflicts in the Balkans. Even the Swiss have been in the news lately due to calls by some for stricter regulations against immigrants. These are just some of the various European issues that could all be the basis for forming new terrorist organizations or strengthening old ones through new alliances.

The tightening of security checks for travelers from Europe causes me to think of a different challenge for those in homeland security. Travelers, those visiting from afar as well as those returning home, are exposed to many different stimulus while away. They have experienced different sounds, languages, sights, smells and food. Travelers entering the country also may have been exposed to contagious diseases. It seems like identifying passengers at risk for spreading communicable diseases is more of a pressing need than restricting travelers from Europe. Two recent stories have help make my point. The first comes from the Centers for Disease Control and Prevention, which reported a woman infected with multidrug-resistant tuberculosis flew aboard American Airlines Flight 293 in mid-December 2007 from New Delhi to Chicago. Earlier in 2007, another traveler, who knew he was infected with tuberculosis, boarded an international flight person. Neither of these individuals were terrorists nor did they subscribe to any kind of nihilistic ideology. They simply thought their need to travel outweighed their obligation to the safety of their fellow passengers. It takes only one individual with a contagious disease to pose a grave threat to hundreds or even potentially thousands of unsuspecting individuals.

The disease that has most been in the news recently is H5N1. The H5N1 virus, or avian flu, has been the focus of attention for the last few years even though this virus has not show a sustainable ability to spread from human to human. The concern is that H5N1 has shown the ability to mutate and it may mutate into a form that could become easily communicable amongst humans creating a worldwide pandemic. However, there are other diseases that already possess the ability to infect large numbers of people at least on an endemic level. Two that have been on the rise are Methicillin-resistant Staphylococcus aureus (MRSA) and anti-biotic resistant tuberculosis. Both are highly contagious and can be spread amongst human beings especially in enclosed spaces such as office buildings or airliners. According to a news article on Reuters, plague, the disease that devastated medieval Europe, is re-emerging worldwide and poses a growing but overlooked threat, researchers warned on Tuesday.

While it has only killed some 100 to 200 people annually over the past 20 years, plague has appeared in new countries in recent decades and is now shifting into Africa, Michael Begon, an ecologist at the University of Liverpool and colleagues said. A bacterium known as Yersinia pestis causes bubonic plague, known in medieval times as the Black Death when it was spread by infected fleas, and the more dangerous pneumonic plague, spread from one person to another through coughing or sneezing. "Although the number of human cases of plague is relatively low, it would be a mistake to overlook its threat to humanity, because of the disease's inherent communicability, rapid spread, rapid clinical course, and high mortality if left untreated," they wrote in the journal Public Library of Science journal PloS Medicine.

Globally the World Health Organization reports about 1,000 to 3,000 plague cases each year, with most in the last five years occurring in Madagascar, Tanzania, Mozambique, Malawi, Uganda and the Democratic Republic of Congo (DRC). The United States sees about 10 to 20 cases each year. The most recent large pneumonic outbreak comprised hundreds of suspected cases in the Democratic Republic of Congo in 2006.

The most recent large pneumonic plague outbreak was in October and November 2006 in DRC, with hundreds of suspected cases, and a smaller outbreak arose just across the border in nearby Uganda in February 2007. "Plague may not match the so-called 'big three' diseases (malaria, HIV/AIDS, tuberculosis) in numbers of current cases," say the authors, "but it far exceeds them in pathogenicity and rapid spread under the right conditions."

It is easier to focus attention on terrorist groups, particularly those abroad, than to deal with ways of identifying passengers with communicable diseases and finding ways of limiting their exposures to others. Advocating stricter types of identification for traveling on airlines may help prevent a known terrorist from boarding a flight but it has not yet been able to stop passengers with known infections of tuberculosis. Perhaps some alienated youth in Europe may be at this moment having visions of attacking the United States but without the organization and funding, he or she will just remain disillusioned. On the other hand, a passenger infected with TB or plague and nothing more than a desire to travel without regard to the safety of others can pose a far greater risk. It was not that long ago some anti-terrorism experts feared a variant of the suicide-bomber scenario where the terrorist intentionally infected himself or herself with smallpox flew into a major airport like O’Hara in Chicago. There the smallpox-infected terrorist would try to physically touch as many individuals as possible in an attempt to spread the disease. It doesn’t take a terrorist to pose a threat to our homeland, just an infected traveler on an airliner. Most are cases of bubonic plague contracted through contact with infected rodents and fleas, although outbreaks of pneumonic plague (directly transmitted from human to human via inhalation of infected respiratory droplets) still occur.

Cincinnati Schools Report a 'Superbug'

Districts Report a ‘Superbug’
Drug-resistant form of staph found in some area schools

http://news.enquirer.com/apps/pbcs.dll/article?AID=/20071024/NEWS01/710240382

According to this morning’s Cincinnati Enquirer, at least four school districts are reporting cases of staph infection. These seem to be the drug resistant variant, methicillin-resistant Staphylococcus aureus (MRSA). School officials stated that this is not indicative of an outbreak. The district disinfected 124 schools to reduce the spread of infection.

MRSA is a bacterium most commonly colonizing around the nostrils and open wounds on the skin. MRSA was first discovered in the United Kingdom in 1961 but has now spread worldwide. It is termed a ‘superbug’ because it has mutated to the point where it can survive treatment with antibiotics to include penicillin and methnicillin.

It is most prevalent in hospitals and schools were there is the greatest incidence of human to human contact. Sanitation is a key in preventing further spread of the disease.

The outbreak here in Cincinnati provides us with an opportunity to evaluate our response to an epidemic and the eventual pandemic outbreak predicted once avian flu (H5N1) mutates into a sustainable, human to human virus. Yes, I know staph is a bacterium while the flu is a virus but the response by the community will involve some of the same factors.

Too often homeland security experts base their analysis on an intentional introduction of a pathogen by a terrorist organization (for example, anthrax). While important, such scenarios miss that Mother Nature is far more successful at introducing contagious diseases than anything think a group of humans can conjure up. The method of introduction gets more attention sometimes that what is being introduced. Infection, whether introduced artificially or naturally, creates the same response challenges for the infected community. For instance, the current MRSA outbreak has caused school officials to send kids home. Good, excellent, remove the vector and reduce the chance of the infection spreading. However, an important question we should be asking is what impact do sending sick kids home have on our economy? Tending to a sick child may require a parent to miss work if other family care arrangements cannot be made. This becomes problematic for those households where both parents work or for single parent households. Right now, the outbreak of MRSA is small enough that the economic impact will be negligible. What if though it continues to spread? More adults will be required to stay at home and also face becoming infected themselves. Work will begin to get disrupted. Services will begin to become impacted. Now adults with kids won’t be the only ones required to stay home, many families have elderly parents at home or other family members that my have compromised immune systems. Those adults may not want to come into work and risk infecting their family members.

Employers are going to have to insure that their workplace is clean and infection free (at least to the degree possible). The challenge will be for those businesses that have customers coming into the workplace, each of these people could potential bring in the infection or take it out of the workplace. Think about the next time you are driving on I-75 or I-71 and see all of the different license plates on the vehicles. You regularly see Michigan, Kentucky, Pennsylvania, Indiana even plates from Canada. All of those vehicles carry people who could potentially either introduce a disease or spread the outbreak to beyond the Cincinnati area. Employers will have to figure ways to minimize the spread of infection without compromising customer service. In addition, some employers may have to accomplish all of this with a reduced workforce.

Granted some business, particularly information technology based industries, will be able to utilize telecommuting and other technologies to allow employees to work from home. But the increased workload on the Internet backbones could cause slower speeds or even failure depending on the magnitude of the crisis. Even in high-tech businesses, some things still have to be accomplished on site. Insuring the safety on their employees will be a major part of successfully navigating the outbreak of a epidemic or pandemic illness.

Hospitals right now can meet the medical needs without any concerns. However, this could change should MRSA (or some other infection) begin to spread. Hospitals could become overrun with ill patients and will have to start sending patients to other hospitals creating a surge at neighboring facilities. Patients already admitted to the hospital for other conditions will now be at risk of exposure to the disease (and most likely these patients will have compromised immune systems). Hospital staff will be challenged with extended shifts and family care issues of their own. Staffing shortages will begin to happen as healthcare workers become sick, tired or just unable to come into work because of family care challenges.

This all assumes an actual outbreak of some kind, however we need to remember that even the threat of an outbreak can create similar challenges. Imagine even people believed avian flu was spreading or that someone had started to send anthrax laced mail again? People would stay away from areas they feel are high-risk (think of the recent flap created when Congressional staffers were advised to get a litany of vaccinations before attending a NASCAR race). Regardless the sanity of the guidance given to the staffers, it does remain valid that a large sporting event such as a NASCAR race could be a terrorist target. The methods that don’t need to involve an actual agent, a simple threat to use such an agent could create the same effect (panic and mass hysteria).

Now is the time to evaluate your procedures at work. We can’t ever stop someone (including Mother Nature) from introducing some type of pathogen into our community, but we can prepare now to reduce the impact to our business and families.