1. Jarris, Paul E. MD, MBA
  2. Talkington, Kathy MPAff

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The news this summer has demonstrated 2 important realities-first, public health must be ready at all times for a variety of scenarios, and, second, medical and social concerns transcend national borders, which has increasingly affected the workload of state, territorial, and freely associated state health leaders. Our interconnection with the globe has been demonstrated by an unexpected influx of children from Central America desperate for a better life, the introduction of a vector-borne disease from the Caribbean not seen in this country before-chikungunya, and most recently the threat of the Ebola virus spreading beyond West Africa. For each of these significant events, public health has played a major role, through its mission to detect, prevent, contain, and treat infectious diseases.


The arrival of unaccompanied children into the United States crossing our southwest border was and continues to be a complex issue, with multiple federal, state, and local entities involved. Federal, state, and local public health entities are maintaining situational awareness on infectious diseases by being familiar with the infectious disease trends in South and Central America and facilitating screenings and preventive measures should they be necessary to protect both the children and the communities they are placed in. This situation has also demonstrated that we have to be prepared for diseases that may not be endemic in our country. For example, although we have been fortunate to see a steady decline of tuberculosis (TB) in the United States in the past 10 years, this trend has been matched with a precipitous decline in public health funding for TB. The screening and treatment systems remain critical to be prepared for the unexpected due to the global threat of this disease confounded by the emergence of strains resistant to standard drug treatment regimens.


The arrival of the mosquito-borne chikungunya virus in the United States is unwelcome news. While not deadly, this virus causes an acute illness associated with severe joint pain and fever that is extremely painful and symptoms can last for weeks. There is currently no vaccine or treatment available for this viral infection. Public health experts around the world have closely monitored the movement of this disease, and our territories and border states have prepared for its expected arrival. The arrival of this virus reiterates the necessity of maintaining effective surveillance networks, diagnostic laboratories, and mosquito control programs both in the United States and around the world. Unfortunately, vector control resources have been slipping into obscurity-some states have lost all capacity to conduct surveillance. According to a 2012 surveillance assessment capacity report, surveillance capacity in state and large city/county health departments has decreased since 2004.1 The percentage of states conducting mosquito surveillance has dropped from 96% to 80%, while more than half of states (58%) have reduced mosquito trapping activities, and 68% have reduced mosquito testing.1 In response to this and other vector-borne disease threats, ASTHO has updated it document, Before the Swarm: Updated Guidelines for the Emergency Management of Vector-Borne Disease Outbreaks, which provides straightforward and realistic guidance to help state and local agencies, nongovernmental organizations, and private industry groups prepare for the emergency management of vector-borne disease outbreaks.2


The worst outbreak of Ebola virus infection is currently raging in West Africa, creating understandable fear of this rare and deadly hemorrhagic fever that has no known treatment or approved vaccine. According to the Centers for Disease Control and Prevention Director, Dr Tom Frieden, the outbreak is


unprecedented in part because it's in a region of Africa that never has dealt with Ebola before and has particularly weak health systems. He said the outbreak's two main drivers are lack of infection control as both health workers and families care for the sick and risky burial practices.3


The only effective prevention and hope for reversing this outbreak is traditional public health practice. The current strategy is to try to contain the spread of the disease through the isolation of infected patients, the practice of strict infection control procedures, and tracking and monitoring contacts. The Centers for Disease Control and Prevention and the state and local health departments have worked furiously to prepare guidance for hospitals and laboratories outlining how to screen for potential Ebola virus-infected patients, how to isolate suspected cases, and how to handle laboratory samples. In addition, they have prioritized the development of informative and effective public health messages about the disease. This outbreak provides a classic demonstration of why public health must maintain situational awareness both abroad and domestically of infectious diseases and why there must be adequate surveillance tools in place to identify new infections or reassure the public about the true threat of disease (or lack thereof). The Ebola response has also demonstrated the important role of public health in communicating quickly and effectively with frontline health care providers to educate them on how to screen for the disease and how to adequately protect hospital employees and the community should a case be confirmed.


Growing global migration, coupled with climate change, has expanded the variety, range, and incidence of infectious diseases in the United States at a time of shrinking federal, state and local budgets for critical public health programs and services. The public expects maximum protection against infectious disease, and the public health community is committed to ensuring that protection. How do we ensure that this level of protection exists?


* Accept that there will always be infectious disease threats-when one ebbs another will flow.


* Establish a public health system that is nimble and well-resourced to adequately address the next threat.


* Enhance current state and local health department capacity for surveillance systems and infrastructure to ensure that it is adequate and capable of handling multiple outbreaks-that is, vector borne, influenza, food borne, etc.


* Think strategically about funding choices (eg, rather than cutting TB funding because the rate of TB is dropping in the United States, maintain that expertise for imported cases, and cross train the workforce to screen for new threats such as Ebola virus infection).


* Develop a system that is flexible enough that it can quickly ramp up in capacity if necessary. The current reality of 3 new responses on top of the existing ongoing activities is taxing the public health system.


* Expand the development of well-integrated public health information systems.



ABC News's Chief Health and Medical Editor, Dr Richard Besser was quoted on This Week saying,


I think we've been far too much in a reactive mode when it comes to new emerging infections. There has to be a much bigger approach, a much bigger effort to try and look at where the next virus will emerge and how we get prepared for that wherever it may occur.4


It is time to have that conversation to seriously evaluate the capacity to respond to multiple issues in an effective way. We need to convene a wide variety of partners from public health, primary care, community groups, business groups, schools, etc-to generate a well-integrated plan for addressing the inevitable next series of outbreaks.




1. Council of State and Territorial Epidemiologists. Assessment of capacity in 2012 for the surveillance, prevention and control of West Nile virus and other mosquito-borne virus infections in in state and large city/county health departments and how it compares to 2004. Accessed August 12, 2014. [Context Link]


2. Association of State and Territorial Health Officials. Before the Swarm: Updated Guidelines for the Emergency Management of Vector-Borne Disease Outbreaks. Accessed August 12, 2014. [Context Link]


3. Neergaard L. CDC Director: scale of Ebola crisis unprecedented. Yahoo News. August 7, 2014. Accessed August 12, 2014. [Context Link]


4. Rea K. CDC Director says U.S. "Surging" efforts to stop Ebola outbreak. ABC News. August 3, 2014. Accessed August 12, 2014. [Context Link]