Monday, December 29, 2014

Ebola: Modern Air Travel the Game Changer for Pandemic Disease

Ebola Virus Photo: CDC
Today, 12, December, 2014, Scotland reported its first case of Ebola. A report in the Guardian suggests that the patient became symptomatic following a flight from Sierra Leone to Heathrow. The Guardian notes: "Urgent steps were being taken by officials with Health Protection Scotland and Public Health England to trace scores of passengers on the nurse’s Royal Air Maroc flight into the UK from Casablanca in Morocco, and the 71 passengers on her internal British Airways connection – BA 1478 – from Heathrow to Glasgow on Sunday night. Nicola Sturgeon, the Scottish first minister and previously Scottish health secretary, said on Monday evening the search for passengers “was very much a precautionary measure”. The nurse, who is believed to be at the early stages of the infection, had been cleared by screening in Sierra Leone and at Heathrow.“The risk to other people as a result of this Ebola case is deemed to be extremely low,” Sturgeon told a press conference." Source:
As the viral load is usually very low at the beginning of the disease and Ebola is thus far not airborn, it is highly unlikely other passengers were exposed, however this case serves to highlight how modern air travel has changed public health security and increases the risk of pandemic disease. Current measure to screen travelers from West African countries, in my personal view, are pointless and in place only to assure the general public. While nations with sophisticated public health infrastures can contain highly pathogenic diseases rather swiftly and the Glasgow case does not pose any threat of epidemic or pandemic, travelers from capital regions in West Africa and transportation to other nations with little or no public health infrastructure poses a more urgent risk. Having sat through years of WHO communicable disease surveillance discussions it is the 'pace not the space' as they say when it comes to disease transmission. In numerous table top exercises and scenario based pandemics which I've developed and run over the years, air travel remains one of the major factors in the how fast disease is spread. Not only are airplanes an ideal inclosed incubator for several hours but the transiting of potentially infected passengers through major airport hubs offer viruses global reach. 
In considering realistic containment strategies, screening passenger for fever would not be one that immediately springs to mind as it is entirely reactionary with little scientific evidence to support this method. Halting air travel or imposing restrictions is often not usually an option and can have devastating impacts on nations which are essentially embargoed. Ideally, when an outbreak of a disease like Ebola or other highly pathogenic diseases emerge as an epidemic, nations with resources such as mobile labs, field hospitals and medical staff must immediately be put in place in country. It may be wise to limit passenger air travel out of endemic regions for defined periods of time and to require all health care workers undergo, in the case of Ebola, a 21 day quarantine in country. This too must be looked after by the international community and resources provided to efficiently manage the transiting of health care workers from paid quarantine in country back to home countries with health certificates clearing them. This would be far more valuable and cost effective than even one case arriving into non-endemic countries. However, in order to actually do this the international community would need to set up a  state of the art treatment center where all health care workers could receive the same treatment they would receive upon evacuation their countries of origin or Europe. Regardless of if the most recent Ebola outbreak continues we need massive investment for West Africa in public health care. To limit transmission through travel, requires not only a state of the art high containment clinic, but more general investment across the board in public health infrastructures. Superficial measures which waste resources should be re-considered. 
If we want to end Ebola we need to keep it from travelling and eradicate it at the first signaling of outbreak, anything less advantages this virus. A total commitment must be made by the international community to develop and maintain public health security in states which can not provide their own. Investment is a global issue and an international responsibility. 

Dr.Jill Bellamy is an internationally recognized expert on biological warfare and defence. She has formerly advised NATO and for the past seventeen years has represented a number of bio-pharmaceutical and government clients working on procurement strategy between NATO MS and Washington DC. Her private government relations consultancy Warfare Technology Analytics is based in the Netherlands. Dr. Bellamy's articles have appeared in the National Review, The Wall Street Journal, The Washington Post, The Sunday Times of London, Le Temps, Le Monde and the Jerusalem Post among other publications. She is a CBRN SME with the U.S. Department of Defence, Chemical, Biological, Radiological and Nuclear Defence Information Analysis Center and CEO of Warfare Technology Analytics.

Sunday, December 28, 2014

Russian Efforts to Respond to the Ebola Crisis

PHIL Image 18150

Both the United States and the Soviet Union ran offensive biological weapon programs up too and during the early 1960's. Both the US and Russia are well placed to respond to the current Ebola outbreak burning across West Africa.  While the running of offensive BW programs should not be considered the gold standard of preventing and controlling future outbreaks of Category A diseases, it does advantage those nations with a wealth of experience which many nations who did not run BW programs simply lack. Unfortunate as it may be, previous BW programs offered research opportunities which don't exist today, but which might prove useful in a post offensive BW era under the BTWC. We should consider that as repugnant as offensive weapon programs were and are in this instance it may well offer postive outcomes.

Notably, Russia has provided two teams to Guinea.  In August, "A decision to dispatch a specialized team of highly qualified experts in virology and epidemiology to western Africa, which has been stricken by an unprecedented epidemic of Ebola fever, was taken by the Russian government. The top-notch mobile lab they took along with them is meant for [conducting] emergency tests on the spot. The experts are staff members from the Louis-Pasteur Institute of Epidemiology and Microbiology in St. Petersburg." "We're sending the top rate professionals there," Russia's Deputy Prime Minister Olga Golodets said Thrusday." See:

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Photo: CDC
Indeed the Russian's, much to their credit, have followed up with a second team of highly trained scientists, a capability and capacity, which most nations would be envious. "The second group of Russian scientists has started diagnosing the disease caused by the deadly Ebola virus in Guinea, the director of Vector Research Center for Virology and Biotechnology said on Tuesday. We have sent a second brigade of virologists to continue work in Guinea," head of the Vector, Valery Mikheyev said." Source: "Russian experts are also working at the Donka Hospital in the Guinean Captial city of Conakry, in close [coordination] with the World Health Organization and Medecins sans Frontieres." Source: Russia Beyond the Headlines -

To date, Russia has sent two highly experienced teams into Guinea with full laboratory capabilities and have made a significant contribution toward ending the outbreak in Guinea. "The second team of scientists, like the first one, is stationed in a mobile laboratory on the basis of a hospital. The experts are using and testing systems developed in 2010 by the Vector Institute to detect six viruses causing deadly fever. Beside Ebola, the testing systems can detect Marburg virus, Lassa fever, Machupo virus, Dengue fever and Yellow fever within 24 hours. The systems were used in the work of anti-epidemic teams at the Sochi Winter Olympics. The Russian testing system for Ebola is the world's only system registered on the national level, Mikheyev said. Other countries use military testing systems to detect the virus, he added." Source:

"According to Russian sanitary chief Anna Popova, "Russia is considering sending further teams of health care workers to West Africa. A team of Russian epidemiologists, virologists and bacteriologists is currently station in Guinea testing anti-Ebola vaccine and has begun working on a new drug to treat and prevent Ebola. Triazavirin is a new Russian anti-viral drug, which can be used to treata 15 strains of the flu virus, including A/H1N1, also known as swine flu and H5N1, known as avian flu, at any stage of the disease."

In contrast, smaller states who have never had a biological weapon program and have stood at the side lines popping up at BTWC meetings to pilfer out superficial admonishments,  lack the depth of knowledge states with previous BW programs no doubt retained. The Netherlands, for example, have recently sent a support ship to West Africa. In fact the Dutch effort seems more for political show than what is realistically required in theatre to control this outbreak.  Efforts by states looking to promote themselves on some international stage by testing a new war ship, in this instance is misguided and possibly inhibits and distracts nations with in-depth knowledge and actual capabilities from doing their work. The worlds worst Ebola outbreak, humanitarian crisis and international public health emergency should not be used as an opportunity to promote the sale or showcase a first in class warship; even with state of the art health care and hospital on board. It is not the time nor place for seeking attention on the international stage.

As thousands of people die from a horrific disease, it is time to allow major nations and organizations with the appropriate resources to contain this outbreak, without distraction. Most actors focusing on saving lives would surely agree that this is not an opportunity for economic gain. Unfortunately, the dire financial straights of the Dutch MoD perhaps leave them with few choices and this detracts from the excellent work of Dutch medical and scientific staff working diligently to help counter the spread of Ebola. While several military medical staff  and public health workers from various nations, including Cuba, have been involved and made valuable contributions to this crisis, sadly some have perceived it as an opportunity for their own financial interests.  

In contrast, Russia and France have quietly undertaken humanitarian efforts and brought suitable resources to actually impact the Ebola outbreak in Guinea, without demonstrations of military hardware, nor for obvious economic gains.France too, has made significant strides as well of course as WHO and MSF both of whom have extensive experience in containment of Ebola outbreaks. In fact far from trying to profit, France has offered 100 million euro to help contain the outbreak and established several Ebola Treatment Units in Guinea. "In response to the appeal by the World Health Organization, Laurent Fabius, Minister of Foreign Affairs and International Development and Marisol Touraine, Minister of Social Affairs and Women's Health Rights, are scaling up France's assistance in the fight against the Ebola epidemic by sending a contingent of healthcare and medical experts to Guinea. Since the start of the epidemic, France has been strongly mobilized to combat the Ebola virus in West Afria, through its research institutes (notably INSERM and the Pasteur Institute, which identified the epidemic as soon as it appeared and are actively contributing to the diagnosis and monitoring of the disease) and its medical experts (who are supporting patient care, the control of the epidemic and the training of personnel alongside local, French and international humanitarian organizations)."
Source: Their efforts are on the cusp of containing and ending the outbreak in Guinea.

Several other nations as well, far from using the tragedy of Ebola to promote themselves with photo ops, hosting high level dignitaries aboard their warships, have contributed in appropriate ways to reduce mortality rates."According to an Oxford University study, the Ebola virus could spread to fifteen tropical African countries, with nearly 22 million people living in the danger zone." Source:
Source: Russia Beyond the Headlines - 
With statements by the 

Dr.Jill Bellamy is an internationally recognized expert on biological warfare and defence. She has formerly advised NATO and for the past seventeen years has represented a number of bio-pharmaceutical and government clients working on procurement strategy between NATO MS and Washington DC. Her private government relations consultancy Warfare Technology Analytics is based in the Netherlands. Dr. Bellamy's articles have appeared in the National Review, The Wall Street Journal, The Washington Post, The Sunday Times of London, Le Temps, Le Monde and the Jerusalem Post among other publications. She is a CBRN SME with the U.S. Department of Defence, Chemical, Biological, Radiological and Nuclear Defence Information Analysis Center and CEO of Warfare Technology Analytics.

Aralsk-7: What a Biological Weapon Accident can Teach us about Containing Disease during Conflict

As the Ebola outbreak in West Africa unfolded I wrote this piece on containment, isolation and quarantine, which I've decided to re-post I will be up-dating this shortly, with a focus on Russian efforts to end the most devastating outbreak of Ebola the international community has ever witnessed.

The potential of loosing command and control of a clandestine military laboratory infrastructure, due to conflict and war, such as exists today in Syria, increases the risk of theft, diversion and the potential for accidental release of highly pathogenic agents into the environment. Where few resources exist to contain epidemics or treat exposed persons, global public health is at increased risk. Modern air travel which can ferry in disease as we have seen with the WPV1 (polio) outbreak in Syria, or carry it out as we see with the Ebola outbreak in Guinea place the intentional community at some risk. Conflict and disease share a long history, but what if an outbreak occurred during a field test where no risk to command and control existed? Containment, in what can only be described as perfect conditions, teaches us about containment during conflict. Two examples stand out: one an 'accident' and the other, a naturally occurring event. In the first instance, in 1971, the Soviet's suffered an accident during a BW test which unfortunately resulted in the deaths of three people. While any loss of life is significant, its worth noting that this was a relatively limited accident, in part due to the immediate measures taken by the Soviet's. Wikipedia has a nice outline on the Aralsk-7 incident which has been widely research to the point of evisceration, but for the purpose of this blog, the basics noted are relatively accurate (see:

The deserted complex of Aralsk-7

"According to Soviet General Pyotr Burgosov (Peter Burgasov), field testing of 400 grams of smallpox at Renaissance Island caused an outbreak on July 30, 1971.(6) Burgasov, former Chief Sanitary Physician of the Soviet Army, former Soviet Vice-Minister of Health and a senior researcher within the Soviet BW program, described the incident: 'On Vozrozhdeniya Island in the Aral Sea, the strongest recipes of smallpox were tested. Suddenly I was informed that there were mysterious cases of mortalities in Aralsk (Aral). A research ship of the Aral fleet came to within 15 km of the island (it was forbidden to come any closer than 40 km). The lab technician of this ship took samples of plankton twice a day from the top deck. The smallpox formulation--400 gr. of which was exploded on the island--'got her' and she became infected. After returning home to Aralsk, she infected several people including children. All of them died. I suspected the reason for this and called the Chief of General Staff of Ministry of Defence and requested to forbid the stop of the Alma-Ata-Moscow train in Aralsk. As a result, the epidemic around the country was prevented. I called (future Soviet General Secretary Yuri) Andropov, who at the time was Chief of KGB, and informed him of the exclusive recipe of smallpox obtained on Vozrashdenie Island.(7)(8). It may never be known whether the release of smallpox was purposeful, but the research ship Lev Berg inadvertently traveled into the plume of this bioweapons release, initiating the smallpox outbreak in Aral. (Some have contended however, that Burgasov was wrong and that the first patient may have contacted the disease while visiting Uyaly or Komsomolsk-on-Ustyurt, two cities in what is now Uzbekistan where the boat docked." (9)(10)

While the outbreak itself has been analyzed to the point of exhaustion, mainly to focus attention on the Soviet BW program,response to the Aralsk-7 outbreak has been relegated to second place, when in fact, the response has quite a bit to offer in terms of 'lessons learned,' and extracting this from whatever political sensitivities one may hold regarding offensive open air field testing, which many states engaged in prior to the 1970's including the United States.  

Medicins Sans Frontieres (MSF) staff attend an Ebola patient inside an isolation ward in Bundibugyo December, 12, 2007 in this picture released by MSF.

"A massive public health response to the smallpox cases in Aral ensued once the disease was recognized. In less than 2 weeks, approximately 50,000 residents of Aral were vaccinated. Household quarantine of potentially exposed individuals was enacted, and hundreds were isolated in a makeshift facility at the edge of the city. All traffic in and out of the city was stopped, and approximately 54,000 square feet of living space and 18 metric tons of household gods were decontaminated by health officials.(15). ( Johnathan B. Tucker and Raymond A. Zilinskas wrote an outstanding and comprehensive analysis of the Aralsk smallpox outbreak in their paper entitled: The 1971 Smallpox Epidemic inAralsk, Kazakhstan, and the Soviet Biological Warfare Program," available at: I highly recommend their publication it is the best analysis I have ever read on the Aralsk incident.  To touch upon the highlights of Soviet containment strategies, Tucker and Zilinskas provide the following:

"Strict quarantine measures were the only way of stopping the further spread of the disease beyond the city, because of late hospitalization and isolation of patients, late diagnoses, and the inability to establish the source of infection. Up until September 26, the quarantine measures were enforced by the police, then beginning at 00 hours on September 26, by the military units of the local garrison and by a SAVO-64411 unit.11 The total length of the cordon around the city was 20-21 km, with soldiers placed at intervals of 700 to 800 meters; in other words, where they were directly visible to each other. The cordon was manned by 23 posts with a total of 200 soldiers. According to Directive No. 4, issued by the district ChPK on September 26, procedures for leaving and arriving at the locale were established, as well as a procedure for tracking and registering outgoing economically vital shipments, whether by road, sea, or rail. " (

"In order to monitor vaccinations and trans-shipments, a total of 5 checkpoints and medical control points were set up near roads leading to Aralsulfat, the Aralsk collective farm, railway junctions No. 86 and 87, and the seaport. Each checkpoint and medical control point was provided with 2 tents for a shift of 4 people and for the medical personnel (2 nurses). Each checkpoint shift was supplied with boiling water, fuel, disinfection equipment and supplies, and hot food. The cordon posts, each of which had 3 personnel, were similarly equipped. The medical control point personnel consisted of 14 nurses and 1 physician. The following work was done at the medical control point: examination and vaccination of 620 people arriving in the city and involved in shipping activities; examination of 82 vehicles with various types of cargo; and disinfection of 32 vehicles. Twelve ships and barges were also monitored. While the quarantine was in effect, several people were detained for violating the quarantine. Ten people were fined, while five were arraigned and had their drivers’ licenses revoked. Internal quarantines covered a zone of medical and preventive facilities, where smallpox patients were identified; i.e., departments of surgery and infectious diseases, skin and venereal disease clinics, as well as newly organized special facilities. The police were responsible for maintaining the quarantine over the hospital, the field hospital, the isolation ward, and the observation facility. A total of 7 posts with 23 personnel were set up. Round-the-clock security was provided for office buildings, with shifts 8 to 12 hours in length." See: From a purely public health perspective, Soviet efforts were impressive as were efforts undertaken by Tito during a smallpox outbreak in 1972. Unfortunately today such strategies would no longer be allowed under most civil society/democratic state law. It is worthwhile to consider that both the Aralsk-7 outbreak and the Yugoslav outbreak were 'accidental.' The use of HPA in a deliberate attack with modified pathogenic agents would present challenges to containment, most states are not willing, let alone prepared to consider. 

The second notable outbreak of highly pathogenic disease, from which lessons can be learned, occurred in Yugoslavia in 1972. Maria Ikovic wrote an excellent comparative analysis entitled: "The 1972 Smallpox Outbreak in Yugoslavia: A Comparison to U.S. Bio-defense," while the paper was written some time ago, the facts remain the same and offer us a chance to consider how gaps in containment strategies today may well effect our ability to contain outbreaks of disease, particularly in conflict zones. pa Ikovic's excellent piece notes the following points: 


  • Over the course of human history, smallpox killed hundreds of millions of people, more than plague and all the wars of the twentieth century combined. It has a 30% fatality rate and severely disfigures most survivors.
  • Smallpox is an orthopox virus that is spread from person to person. There are no known animal or insect hosts.
  • The virus is most transmittable in cold weather.The Yugoslavian outbreak occurred during February-April, after a single infected person (the index case) returned from a Muslim pilgrimage inSaudi Arabia, passing by bus through Iraq (infected with smallpox at the time).
  • The incubation period (from the moment of infection until the onset of symptoms) lasts 7 to 17 days. Persons with the virus are not contagious during the incubation period. No one else on the bus to Yugoslavia contracted smallpox (there were 25 other passengers on the bus).
  • After the incubation period patients spread smallpox primarily to household members, friends, and hospital workers. This is due in part to the fact that transmission of the virus occurs in conjunction with the onset of symptoms including fever and rash. In other words, the virus is communicable only when a person is typically bedridden. The Yugoslavia case confirms this generalization: Muzza infected 38 people, all but one of whom were hospital contacts. However, the index case experienced a mild form of the disease; he was not bedridden and was therefore able to spread it to Muzza.
  • Once communicable after the incubation period, the virus spreads primarily through droplet nuclei oraerosols expelled from the host by exhaling or coughing. When the virus is breathed in it infects the respiratory passages, spreading to the lymph nodes and elsewhere.
  • Infection may also occur through contaminated bed linen and clothing.
  • Rates of transmission are disputed: Some estimate that each infected person infects a further 10-13; others estimate that each infected person infects 1-3 others. The Yugoslavian transmission ration was 1:13. Other studies, however, looked at past outbreaks and estimated average rates of transmission to be lower than 2.
Photo taken of smallpox patient in Kosovo, 1972
  • Diagnosis is often difficult, particularly when healthcare providers are not familiar with symptoms. In Yugoslavia prior to the 1972 outbreak, the last death from smallpox was registered in 1926. As a result healthcare providers were unfamiliar with the disease. When Muzza was hospitalized (at various hospitals in Yugoslavia) doctors misdiagnosed him as having an allergic reaction to penicillin, when in reality he was affected with a highly fatal form of smallpox.
  • After the incubation period the patient first experiences influenza-like symptoms, such as fever, malaise, and prostration. This is followed by the onset of a rash, the bumps of which are in the skin, not on it. The rash becomes severe, turning into pustules that are hard and round.
  • Smallpox is often confused with chickenpox. However, the smallpox rash is centrifugal: it is concentrated more on the head, hands, and feet than it is on the trunk. The chickenpox rash is the opposite: it appears primarily on the trunk, and never on the palms or soles of hands and feet. 
  • The rash eventually turns into scabs that fall off and typically leave deep pits on the skin. The person is considered contagious until the last scab separates.
Control of Outbreaks:

Checking immunization reaction, Kosovo, 1972
  • The Vaccine is extremely effective, but gives the recipients full immunity from smallpox for 3-5 years, with decreasing immunity thereafter. The Yugoslavian index case likely experienced a mild case of smallpox because he had been immunized just months before.
  • Vaccination complications: For every one million people inoculated, one will die, 14 will be infected with life-threatening illness, and 48 will suffer less serious illnesses. 
  • Two main ways to inoculate during an outbreak:Mass Vaccination and Ring Vaccination. With the latter, only suspected contacts are vaccinated. The former method was used in Yugoslavia: a state's entire population is vaccinated (or as was typically the case in Yugoslavia revaccinated)
Key points in the Yugoslavia Epidemic
  • It was a natural outbreak
  • There was a high transmission rate DESPITE PRIOR VACCINATIONS. One infected person infected     13 others, on average. The high transmission rate was probably aggravated by winter temperatures and late diagnosis.
  • Containment strategy=Mass (re)vaccination and Quarantine.
  • Tito was ruling at the time; political system (authoritarianism) was suited for draconian measures. Emergency procedures included the isolation of Dakovica province, shutting down borders, quarantining all persons suspected of coming into contact with the virus, and prohibiting public events, meetings and weddings. 20 million people were vaccinated and 10,000 contacts were quarantined.
  • Over a 9 week outbreak, 175 people were infected, 35 died. OUt of 175 affected persons, 105 (60%) had been previously vaccinated against smallpox, whereas 37.7% had not been immunized; the vaccinal status was unknown for 2.3% of the affected persons. See:
"West Africa is seeing the 'most challenging' outbreak of Ebola virus since the disease was discovered 40 years ago. It comes as the death told reaches over 101, the World Health Organization reported. This is the most challenging Ebola outbreak we have ever faced," Keiji Fukuda, Assistant Director General of the World Health Organization (WHO) told a news briefing. See:

Considering the recent outbreak of Ebola in Guinea, there have been 21 reported cases in Liberia with 10 fatalities, and 9 suspected cases in Mali. Most concerning are the 20 cases reported in Conakry, the capital, 16 of which have been laboratory confirmed. "Médecins sans Frontières (MSF/Doctors without Borders) is helping the Ministry of Health of Guinea in establishing treatment and isolation centers in the epicenter of the outbreak. In Liberia, several international organizations including the International Red Cross (IRC), Pentecostal Mission Unlimited (PMU)-Liberia, and Samaritan’s Purse (SP) Liberia are aiding the Ministry of Health of Liberia by supporting awareness campaigns and providing personal protective equipment (PPE) for healthcare workers. The Institute Pasteur in Lyon, France, the Institute Pasteur in Dakar, Senegal, the European Consortium mobile laboratory, and the Metabiota/Tulane University laboratory in Kenema, Sierra Leone, and CDC Atlanta are some of the laboratories collaborating to test samples. To date, 56 cases from Guinea and Liberia have been laboratory confirmed by PCR for Ebola virus. CDC is in regular communication with its international partners, WHO, and MSF regarding the outbreak and a 5 person CDC team is currently in Guinea assisting the Guinea MOH and the WHO-led international response to this Ebola outbreak."Based on Guinea’s MoH Epidemiological Bulletin, Liberia’s MoH, and the WHO update 5 April, 2014. 

A brief note on the difference between isolation and quarantine, provided on the HHS website:    Isolation and quarantine are public health practices used to stop of limit the spread of disease. Isolation is used to separate ill persons who have a communicable disease from those who are healthy. Isolation restricts the movement of ill persons to help stop the spread of certain diseases. For example, hospitals use isolation for patients with infectious tuberculosis. Quarantine is used to separate and restrict the movement of healthy persons who may have been exposed to a communicable disease to see if they become ill. These people may have been exposed to a disease and do not know it, or they may have the disease but do not show symptoms. Quarantine can also help limit the spread of communicable disease. 

Similar to Ebola, outbreaks of smallpox, which swept across Europe killing over 300 million in the Twentieth Century alone, caused panic and loss of life. Fortunately, smallpox is now a vaccine preventable disease, Ebola is not. The utility of quarantine should not be underestimated particularly in the absence of a vaccine or other medical counter-measures.
In contrast to perfect conditions where quarantine, isolation and vaccination can be swiftly implemented with few civil rights issues,  outbreaks which happen in conflict zones are cause for far greater concern. When we consider outbreaks of disease in Syria or even the recent outbreak of Ebola in Guinea, containment strategies utilized in Aralsk and Yugoslavia, which include isolation, quarantine and if possible vaccination (only experimental vaccines are available for Ebola), are enviable. Today it would be nearly impossible to institute such effective strategies.  Inability to impose strict isolation and quarantine, make research and development of medical countermeasures all the more urgent. Providing public health care during war requires modelling which thus far has not been terribly impressive, even in states with adequate resources.

Dr.Jill Bellamy is an internationally recognized expert on biological warfare and defence. She has formerly advised NATO and for the past seventeen years has represented a number of bio-pharmaceutical and government clients working on procurement strategy between NATO MS and Washington DC. Her private government relations consultancy Warfare Technology Analytics is based in the Netherlands. Dr. Bellamy's articles have appeared in the National Review, The Wall Street Journal, The Washington Post, The Sunday Times of London, Le Temps, Le Monde and the Jerusalem Post among other publications. She is a CBRN SME with the U.S. Department of Defence, Chemical, Biological, Radiological and Nuclear Defence Information Analysis Center and CEO of Warfare Technology Analytics.

Friday, December 26, 2014

Strategic Stockpiling After Ebola: Lessons Learned

Not loaded
                                                  Photo By: 1st Lt. Rusty Ridley, Air National Guard

All NATO states and the EU have strategic national stockpiles (SNS). SNS comprise a nations repository of vaccines, anti-virals, anti-toxins and a range of critical care medical equipment and technologies to support mass casualty care in the event of an emergency involving bio-terrorism, pandemics or natural disaster. The US SNS has a response time of approximately 12 hours and is located in stockpiles throughout the United States. In contrast, NATO maintains a 'virtual' stockpile with nations designating available supplies should an outbreak, either deliberate of natural require the intervention of NATO medical sections associated with COMEDS. 
A vital aspect of NATO's SNS, which can also be conceived of as a real SNS as each Member State must stockpile anything it designates for contribution should a crisis aise is procurement and procurement based on risk analysis. The on-going Ebola outbreak in West Africa will no doubt teach us the finer points of critical care stockpiling. Several NATO states have sent military support to affected nations in West Africa. Not only must their health care workers and military personnel be potentially treated should they contract Ebola or other endemic diseases such as Malaria and Lassa, (to date around 10% of Ebola cases have been health care workers), but returning military personnel must be considered as well). NATO Member State SNS have pushed vital medical supplies to West Africa. Gaps in stockpiling and risk based audits must now be conducted to understand which technologies, anti-virals, antibiotics, diagnostic technologies, barrier products should be procured in greater quantities and which should be reduced from our stockpiles.

Over the course of this Ebola outbreak, procurment officers have no doubt had a sharp learning curve regarding which products, materials, technologies and therapeutics are key to containing not just an Ebola outbreak, but applicable to a range of infectious disease outbreaks and which are not. In a discussion with one of the highest ranking public health officers in the US last week, I was informed that it was highly likely the composition of the SNS will shift to take into account lessons learned from the worst outbreak of Ebola in history. Likewise NATO will no doubt refine its advice on SNS, with a more risk based approach applied over the coming years. Gaps which define inadequacies in our stockpiling are particularly relevant, such as availability of personal protective equipment, respirators, support therapies, drugs and diagnostic equipment as well as issues related to working in environments with little or no consistent energy supply. The cold-chain issue with vaccines is a case in point and offers an opportunity to develop technologies which overcome this issue, so vaccines and therapeutics are no longer dependant upon maintaining a cold-chain. Development of such technology includes a range of exciting innovative solutions.  

As the CEO of Warfare Technology Analytics, based in the Netherlands, it has been an intense time of reviewing technologies which should be promoted for inclusion in NATO Member State strategic stockpiles. A number of technologies have been presented to me, not purely related to anti-virals, therapeutics and medical counter-measures, but diagnostic tools which I am likely to promote in the near future as highly valuable for our SNS across NATO states. Diagnostics proved to be a critical issue in this outbreak and one which is often overlooked in the composition of SNS. Additionally one of the positives to emerge from this crisis has to be the rapid advancement of technologies to control outbreaks of highly pathogenic diseases. I am looking forward to working with a number of firms producing technologies to contain outbreaks not purely at the drug level. Although the mortality rate and continued public health crisis in West Africa is alarming, if we take anything positive away from this crisis it has to be the inspiring development of a range of technologies we would perhaps have spent years trying to acquire. I look forward to reviewing technologies for procurement over the next few years in our SNS and to ensuring we are prepared and our forces protected against both deliberate and naturally occurring disease. 

Thursday, December 25, 2014

Up-Coming: The Myth of Public Health Security in an age of Pandemic Disease

Draft version preview
PHIL Image 17904
Ebola Isolation Center Freetown 2014, Image CDC
The concept of public health security emerged sometime after the US anthrax attacks and came to be associated with deliberate disease as well as developing coordinated infrastructures to protect against outbreaks of naturally occurring, highly pathogenic diseases such as Ebola. If anything the West African Ebola outbreak demonstrates it is surely failures in public health security and international preparedness to counter emerging diseases which have the potential to go global. At the heart of preparedness however, is investment in public health infrastructures, not only in NATO, EU  and developed nations, but more importantly in nations which cannot support a public health capability. The three nations worst hit by Ebola: Guinea, Liberia and Sierra Leone were in the process of reconstituting their respective public health sectors after years of civil strife, when Ebola began ravaging the fragile structure. The World Health Organization which operates on a budget the size of a general hospital was left with few resources to respond. One can imagine the enormity of the task. Building a sufficient public health infrastructure absent civil war and the worst outbreak of Ebola in history would be a nearly insurmountable challenge doing this while Ebola ravaged these nations and wiped out entire villages is an effort no one would envy having to scavenge together.
PHIL Image 17809

Ebola, like other highly infectious diseases is transmissible and its emergence in all three capitals where transportation could expedite it going global, was a wake up call for most public health officials. As nations consider resources designated to protect their own nationals, it is important to recognized the number one lesson of this outbreak: investment in weak or non-existing public health infrastructures is an investment for all.  

Ebola, Emerging Pandemics and Synthetic Viruses

Ebola: photo NIAID

“Viruses like Ebola are notoriously sloppy in replicating, meaning the virus entering one person may be genetically different from the virus entering the next. The current Ebola virus’s hyper-evolution is unprecedented; there has been more human-to-human transmission in the past four months than most likely occurred in the last 500 to 1,000 years.”[1]

A National Geographic article entitled, “Tracking a Serial Killer: Could Ebola Mutate to Become More Deadly?” David Quammen notes that “Ebola virus is a zoonosis, meaning an animal infection transmissible to humans. The animal in which a zoonosis lives its customary existence, discreetly, over the long term, and without causing symptoms, is called a reservoir host."2. "The reservoir host of Ebola virus is still unknown—even after 38 years of efforts to identify it, since the original 1976 outbreak—although one or more kinds of fruit bat, including the hammer-headed bat, are suspects. There are hammer-headed bats in southeastern Guinea In. It's possible that somebody killed one for food and brought it to Meliandou, where the child became infected either by direct contact with the bat or by virus passed on the hands of an adult.”3

Quammen continues to question why such facts and suppositions are significant. He reminds us that Ebola virus abides endemically in the forests of equatorial Africa. “It will never be eradicated as long as those forests exist, unless the reservoir host itself is eradicated (not recommended) or cured of the viral infection (not likely possible). The virus may retire into its hiding place for years at a time, but eventually it will return, as a result of some disruptive contact by humans with the reservoir host. Then it will spill over  will into us again. All thinking and planning about how to defend against Ebola virus disease in the future needs to take account of that reality.”4
The race to develop a vaccine is of course crucial for this particular outbreak and while it provided a wake up call to many in the bio-defence and public health communities alike, planning for emerging and reemerging disease strategies of the future will require the development of technologies in addition to vaccines and therapeutics. If, for example, diagnostics could have been run within minutes instead of hours or days, surely this most recent outbreak would have come under control more swiftly. While it is encouraging to see the international community call for vaccines this misses the point that preparing for pandemics requires an approach which is long term, not reactionary yet still responsive to swiftly changing conditions on the ground.  It requires a strategic approach that addresses public health care from a position which acknowledges future pandemics are highly likely and drug development and discovery, technology  and applications must be broad based to cover consecutive and unknown emerging pandemics. 
Fortunately, a number of anti-virals have had some success in vitro showing efficacy against this latest EBV, but we have had experience with Ebola and drug development had been on-going by several pharmaceutical firms prior to this recent outbreak. How comfortable are we with the idea of a synthetically produced viral outbreak going global? While it may seem, in the midst of the worlds worst Ebola outbreak, a bit remote to consider, perhaps a bit unreal, so too was the idea last year that an Ebola outbreak, one which we had previous experience in quickly containing, would claim the lives of 7,500 people and infect nearly 20,000. Preparation is key to containment. Colleagues today racing to find a vaccine or therapeutic against this epidemic would I'm sure suggest they are too busy coping with this outbreak to consider such luxury problems one envisions with the concept of 'synthetic biology' or 'synthetic viruses.' Yet we should pay close attention when Craig Venter, proposes bio-technologies such as the ability to 3D print vaccines  to counter this exact scenario. The message should be Ebola is bad but things could be much worse and we need to be planning for these eventualities in a comprehensive way, not simply racing to put out fires on the ground with squirt guns.  

Dr.Jill Bellamy is an internationally recognized expert on biological warfare and defence. She has formerly advised NATO and for the past seventeen years has represented a number of bio-pharmaceutical and government clients working on procurement strategy between NATO MS and Washington DC. Her private government relations consultancy Warfare Technology Analytics is based in the Netherlands. Dr. Bellamy's articles have appeared in the National Review, The Wall Street Journal, The Washington Post, The Sunday Times of London, Le Temps, Le Monde and the Jerusalem Post among other publications. She is a CBRN SME with the U.S. Department of Defence, Chemical, Biological, Radiological and Nuclear Defence Information Analysis Center and CEO of Warfare Technology Analytics.

[1] Virology Blog about Viruses and Viral Disease, 18 September, 2014. URL:
2 Quammen, David, "Tracking a Serial Killer: Could Ebola Mutate to become more deadly?" National Geographic, 15, October, 2014. URL:
3 Ibid., Quammen
4 Ibid., Quammen

Ebola: Lost Opportunities in Case Management, Therapeutic Development and Diagnostic Testing

"As the Ebola outbreak has burned its way deep into Guinea, Liberia, and Sierra Leone, in one of the worst acute public health crises in 50 years, our academic medical centers have sat largely on the sidelines. They have spent a fortune preparing their facilities and staff for the much-feared scenario of a local patient with possible Ebola virus infection. What has been lacking is leadership to help quell the crisis where it is actually happening. The problem is more than a lack of effective, positive leadership, as Rosenbaum reports4: the difficulties created by many academic medical centers for trainees and staff who want to go to West Africa to help control this outbreak are more akin to roadblocks. This response stands in contrast to that in the United Kingdom, where the Wellcome Trust has encouraged academic institutions to join the fight and has provided emergency funding for their research initiatives, and to that of the U.S. National Institute of Allergy and Infectious Diseases, which is offering extensions for grant renewals to people who have taken time to participate in Ebola mitigation efforts."1

It is important to recall that the West African nations hit hardest by Ebola experienced years of war and civil unrest. Against this backdrop, public health care was struggling to emerge. Previously West Africa had not experienced an outbreak of Ebola, in the three nations now at the epicenter of this disease. "The three countries which are most affected: Sierra Leone, Guinea and Liberia, are among the poorest in the world, with extremely low levels of literacy, few hospitals or doctors, poor physical infrastructure and poorly functioning government institutions."2 Against this backdrop it is understandable that the mechanisms for trialing drugs and diagnostics were not in place prior to the outbreak however, a picture is emerging of increasing obstacles not directly related to the situation on the ground itself, but from those agencies charged with bringing the outbreak under control. 

"The leaders of academic medical centers that have put roadblocks in the path of those wishing to serve need to rethink their priorities. They should be making it easier, not harder, for altruistic physicians, nurses, and other health care providers to help care for the sick and control the Ebola epidemic in West Africa. Our medical centers have immense resources and expertise; the countries wracked by Ebola have almost none. Something is wrong when some of the greatest health care centers in the world are not helping in the fight against this disastrously dangerous threat to human health."2

While providing health care workers to West Africa is a noble cause, it is critical we put into place mechanisms which not only allow medical staff to transition for several weeks into Ebola Treatment Unit's (ETU's) but that we put in place mechanisms which allow several drugs and diagnostic technologies to be run simultaneously, particularly those which meet the criteria defined by the UN/WHO. Better coordination on the ground is key and it is certainly complicated by a lack of existing infrastructures. Given the situation across West Africa, international public health communities with their existing infrastructures and capacity to identify and treat Ebola cases must look for ways to overcome roadblocks and obstacles, some pre-existing to the outbreak but others put in place by perhaps well meaning organizations attempting to control a situation which was beyond control. While competition drives incentive, in this instance where thousands of lives are on the line it is more important to collaborate than compete and it is critical to trial as many therapeutics which meet the established criteria as possible. This is not yet the case in West Africa, drugs which have a high probability of benefit for Ebola patients are shut out of the process of trialing to the detriment of public health. What has become clear over the last few months is that we need a mechanism which allows the pharmaceutical industry to compete equally provided they meet established scientific protocols. 

Dr.Jill Bellamy is an internationally recognized expert on biological warfare and defence. She has formerly advised NATO and for the past seventeen years has represented a number of bio-pharmaceutical and government clients working on procurement strategy between NATO MS and Washington DC. Her private government relations consultancy Warfare Technology Analytics is based in the Netherlands. Dr. Bellamy's articles have appeared in the National Review, The Wall Street Journal, The Washington Post, The Sunday Times of London, Le Temps, Le Monde and the Jerusalem Post among other publications. She is a CBRN SME with the U.S. Department of Defence, Chemical, Biological, Radiological and Nuclear Defence Information Analysis Center and CEO of Warfare Technology Analytics.

1Jeffrey M. Drazen, M.D., Edward W. Campion, M.D., Eric J. Rubin. M.D., Ph.D., Stephen Morrissey, Ph.D., and Lindsey R. Baden M.D., "Ebola in West Africa at One Year From Ignorance to Fear to Roadblocks", The New England Journal of Medicine. December 24, 2014DOI: 10.1056/NEJMe1415398 URL:
2 "A Concrete Response to the Ebola Outbreak Cannot Wait", UNICEF. Retrieved 26, December, 2014.
3 Drazen, Campion, Rubin, Morrissey and Baden, "Ebola in West Africa One year From Ignorance to Fear to Roadblocks", URL:

Virus Like Particle Vaccine Technology Applications

Virus Like Particle Vaccines (VLP) are multiprotein structures that mimic the organization and conformation of authentic native viruses but lack the viral genome, potentially yielding safer and cheaper vaccine candidates. A handful of prophylactic VLP based vaccines are currently commercialized worldwide: GlaxoSmithKline's Engerix (hepatitis B virus) and Cervarix (human papillomavirus), and Merck and Co., Inc.'s Recombivax HB (hepatitis B virus) and Gardasil (human papillomavirus) are some examples. See:

According to the Salk Institute site, "Virus like particles are supra molecular assemblages incorporating key immunologic features of viruses which include repetitive surfaces, particulate structures with potential for induction of innate immunity through activation of pathogen associated molecular pattern recognition receptors. They carry no replicative genetic information and can be produced in heterologous expression systems at large scale. VLPs thus represent a safe and effective vaccine platform with potential to induce potent B and T cell responses. In addition to being effective vaccines against the corresponding viruses from which they are derived, virus like particles can also be used to present foreign epitopes to the immune system. This can be achieved by genetic fusion or chemical conjugation. This technological innovation has greatly broadened the scope of their use, from immunizing against microbial pathogens to immunotherapy for chronic diseases. Towards this end, VLP have been used to induce auto antibodies to disease associated self-molecules involved in chronic diseases such as hypertension and Alzheimer's disease. The recognition of the potent immunogenicity and commercial potential for VLP's has greatly accelerated research and development activities. During the last decade two prophylactic virus like particle vaccines have been registered for human use, while another 12 vaccines entered clinical development." See:

While major pharmaceuticals such as Merck and GSK are well into the VLP production stage, a couple other firms have recently caught my attention. Sentinext Therapeutics is working to develop a bivalen VLP against hand, foot and mouth disease (HFMD) See: hfmd#.Uwswl_15MVY According to a press release on Sentinext Therapeutics, their VLP based vaccine is intended to protect against 95% of viruses causing HFMD in comparison to EV71 vaccines that give protection against only 65-75% of viruses. Targeting the two major viruses, EV71 and Coxsackievirus A16, that cause HFMD in the Asia Pacific region. 'Up to 35 percent of the HFMD cases during outbreaks are caused by CVA16, whereas, all competing vaccines are monovalent EV71 vaccines. This gives an advantageous platform to bivalent vaccines as an EV71 monovalent vaccine will not protect against HFMD caused by CVA16 and virological diagnosis will be required in efficacy trials. Bivalent HFMD vaccine will facilitate efficacy trials with protection against HFMD as the clinical endpoint," says Dr. Cardosa. See:

Medicago, a biopharmaceutical company focused on developing highly effective and competitive vaccines based on proprietary manufacturing technologies and VLP's has achieved successful completion of a key milestone under an agreement with the Defence Advanced Research Projects Agency (DARPA). The milestone was the production of at least 10 million doses of H1N1 VLP influenza vaccine candidate in one month. This rapid fire test was conducted at Medicago's facility in Durham, North Carolina." See:

Dr.Jill Bellamy is an internationally recognized expert on biological warfare and defence. She has formerly advised NATO and for the past seventeen years has represented a number of bio-pharmaceutical and government clients working on procurement strategy between NATO MS and Washington DC. Her private government relations consultancy Warfare Technology Analytics is based in the Netherlands. Dr. Bellamy's articles have appeared in the National Review, The Wall Street Journal, The Washington Post, The Sunday Times of London, Le Temps, Le Monde and the Jerusalem Post among other publications. She is a CBRN SME with the U.S. Department of Defence, Chemical, Biological, Radiological and Nuclear Defence Information Analysis Center and CEO of Warfare Technology Analytics.

The U.S. Strategic National Stockpile: Ensuring rapid bio-defence during conflict

"A number of agents to counter biological threats are included in the Strategic National Stockpile (SNS), such as smallpox and anthrax vaccines. The U.S. Department of Health and Human Services and the CDC consider many factors, such as current biological threats, the availability of medical material, and the ease of dissemination of pharmaceuticals. One of the most significant factors in determining SNS composition, however, is the medical vulnerability of the U.S. civilian population." See:

According to The Association of State and Territorial Health Officials, "The U.S. Strategic National Stockpile (SNS) program is designed to supplement and resupply state and local inventories of medicines and supplies during emergencies severe enough to exhaust local supplies (3). Decisions about what medicines and materials should be included in the SNS are made by the HHS Assistant Secretary of Preparedness and Response (ASPR), the HHS, the Department of Homeland Security (DHS) and the CDC, in consultation with state and local public health officials and private sector organizations and entities. In determining and reviewing the composition of SNS assets, the HHS and the CDC look at multiple factors, including the medical vulnerability of the U.S. population (and of at risk populations such as children and other vulnerable populations), currently biological/chemical threats, the availability of medicines and medical supplies, and the ease of disseminating specific medicines.(4) See: 

But what effect does or should, conflict play in the composition of the SNS and to what extent are these issues sufficient to merit an increase specifically in vaccines and anti-toxins in the event of a biological accident or deliberate event?
While conflict, specifically in states which are suspected of conducting offensive biological weapon research, is worrisome, other factors such as rapid production  of and use of licensed and non-licensed products is a compelling topic. In a recent paper entitled "Making Vaccines 'on demand': A potential solution for emerging pathogens and biodefence? (See:, the authors note:

"The integrated US Public Health Emergency Medical Countermeasures Enterprise (PHEMCE) has made great strides in strategic preparedness and response capabilities. There have been numerous advances in planning, bio-threat countermeasure development, licensing, manufacturing, stockpiling and deployment. Increased biodefense surveillance capability has dramatically improved, while new tools and increased awareness have fostered rapid identification of new potential public health pathogens. Unfortunately, structural delays in vaccine design, development, manufacture, clinical testing and licensing processes remain significant obstacles to an effective national biodefense rapid response capability. This is particularly true fro the very real threat of 'novel pathogens' such as the avian-origin influenzas H7N9 and H5N1, and new coronoaviruses such as hCoV-EMC. Conventional approaches to vaccine development, production, clinical testing and licensing are compatible with the prompt deployment needed for an effective public health response. An alternative approach, proposed here, is to apply computational vaccine design tools and rapid production technologies that now make it possible to engineer vaccines for novel emerging pathogens and WMD biowarfare agent countermeasures in record time. These new tools have the potential to significantly reduce the time needed to design string of epitope vaccines for previously unknown pathogens. The design process--from genome to gene sequence, ready to insert in a DNA plasmid-can now be accomplished in less than 24 hours." Syria's use of chemical weapons detailed in a UN Report ( confirms what had been suspected for over two decades. It is suspected as well that Syria has an agile BW program. Given the current and on-going conflict in Syria, review of the composition of the US SNS as well as the push for advanced vaccine manufacturing is timely. If we compare the previous composition, from a 2011 report by MedFrontiers they detailed several contracts which included: 
  • 691 million USD for 29 million doses of the current approved anthrax vaccine (anthrax vaccine absorbed or AVA) from Emergent BioSolutions, Inc.
  • 334 million for 65,000 doses of Raxibacumab (ABthrax), a treatment for anthrax from Human Genome Sciences Inc.,
  • 144 million for 10,000 doses of Anthrax Immune Globulin, a treatment for anthrax from Cangene Corporation
  • 505 million for 20 million doses of a smallpox vaccine (Modified Vaccinia Ankara or MVA) from Bavaria Nordic, Inc.
  • 433 million for 1.7 million doses of ST-246, an antiviral treatment for smallpox from SIGA Technologies Inc.
  • 414 million for 200,000 doses of botulinum antitoxin, a treatment for botulinum toxin exposure, from Cangene Corp.
  • 18 million for 5 million doses of a pediatric form of potassium iodide, a treatment for radioactive iodine exposure from Fleming Pharmaceuticals
  • 22 million fro 395 doses of  pentetate calcium trisodium (also known as CA-DTPA) and 80,000 doses of pentetate zinc trisodium (also known as Zn-DTPA), two treatments for internal radioactive particle contamination from Akorn Inc. See: 

How agile is the US Strategic National Stockpile at rapid procurement for bio-defence vaccines and counter-measures during conflict and crisis in states which could posses a BW complex and which could loose command and control over that complex? Are we able to swiftly acquire vaccines for example for synthetic agents? Global BioDefence notes in an article entitled, 'Biodefence Contracts Feed US Stockpile of Anthrax Anti-toxin," that Under Bio-Shield contracts "HHS will order approximately 196 million in antitoxin from GlaxoSmithKline. In addition, HHS will purchase materials to manufacture antitoxin. The materials include blood plasma from Cangene for approximately 63 million and a total of 1.6 million in cells from GlaxoSmithKline, PharmAthene, and Emergent. PharmAthene and Emergent have antitoxin at earlier stages of development than the GlaxoSmithKline and Cangene products. Today's actions build on efforts by all five companies and the federal government to develop anthrax antitoxins. Human Genome Sciences, acquired by GlaxoSmithKline, and Cangene began delivering to the stockpile in 2009 and 2007, respectively." For full article see:
Jill Bellamy is an internationally recognized expert on biological warfare and defence. She has formerly advised NATO and for the past seventeen years has represented a number of bio-pharmaceutical and government clients working on procurement strategy between NATO MS and Washington DC. Her articles have appeared in the National Review, The Wall Street Journal, The Washington Post, The Sunday Times of London, Le Temps, Le Monde and the Jerusalem Post among other publications. She is a CBRN SME with the U.S. Department of Defence, Chemical, Biological, Radiological and Nuclear Defence Information Analysis Center and CEO of Warfare Technology Analytics, a private consultancy based in the Netherlands.