“On average, in one corner of the world or another, a new infectious disease has emerged every year for the past 30 years: mers, Nipah, Hendra, and many more.
…Despite advances in antibiotics and vaccines, and the successful eradication of smallpox, Homo sapiens is still locked in the same epic battle with viruses and other pathogens that we’ve been fighting since the beginning of our history. When cities first arose, diseases laid them low, a process repeated over and over for millennia. When Europeans colonized the Americas, smallpox followed. When soldiers fought in the first global war, influenza hitched a ride, and found new opportunities in the unprecedented scale of the conflict. Down through the centuries, diseases have always excelled at exploiting flux…
Perhaps most important, the U.S. is prone to the same forgetfulness and shortsightedness that befall all nations, rich and poor—and the myopia has worsened considerably in recent years. Public-health programs are low on money; hospitals are stretched perilously thin; crucial funding is being slashed. And while we tend to think of science when we think of pandemic response, the worse the situation, the more the defense depends on political leadership.
When Ebola flared in 2014, the science-minded President Barack Obama calmly and quickly took the reins. The White House is now home to a president who is neither calm nor science-minded. We should not underestimate what that may mean if risk becomes reality.” (A)

“Disease tends to spread more easily and more rapidly among denser populations. And as populations grow, they can put a greater strain on already stretched resources, from sanitation to medical resources such as vaccines. Over the last few years, we have seen demand for emergency stockpiles of vaccines for diseases like cholera and yellow fever increase dramatically. While we can currently meet this demand, the growing number of mega-cities with populations of 10 million or more, and the increasing risk of urban epidemics that come with them, could deplete these stockpiles very quickly…
While stockpiles are essential, they remain only part of the solution. As cities continue to grow, our best defense will be anticipating outbreaks before they occur. For some diseases, that means making childhood immunization and pre-emptive vaccination campaigns a priority. In other cases, it may mean greater investment in sanitation infrastructure, which can help prevent not just cholera but other water-borne diseases, like the diarrhea-causing rotavirus. And many poor countries are in desperate need of basic diagnostics and surveillance capabilities, enabling them to detect an outbreak as early as possible gives them an opportunity to quickly respond.
All too often with infectious diseases, it is only when people start to die that necessary action is taken. To avoid this, the answer is simple: All countries must step up their long-term efforts to prevent and, wherever possible, eliminate infectious disease. If we keep waiting until outbreaks occur, we may soon find that our ability to respond, contain, and end them is gravely inadequate.” (B)

“Even for outbreaks with excellent vaccines, supplies cannot always be ready fast enough. Once supplies are ready to bring to market, they still need to be fitted into the supply chain, stored properly, and transported to the appropriate individuals — wherever they are.
The logistical issues can be enormous. We are seeing those issues with the experimental Ebola vaccines in the Democratic Republic of the Congo now as aid workers use small boats or motorbikes carrying portable freezers of vaccine to reach remote villages. Vaccines must be administered properly. That means recruiting and training medical professionals and educating the public so that people seek out and receive a vaccine. It also means tracking doses and side effects.
This is why preparedness is vital. Vaccines have a very specific function for containing disease. But even if we develop a vaccine for every possibility, they still have limitations. Local communities must therefore be prepared to prevent and contain outbreaks and limit the impact of those outbreaks on health care and public services.
Preparation means having comprehensive, resilient primary health care services and systems in place with working components: strong leadership, engaged communities, laboratories and hospitals, pharmaceutical systems, supply chains, and disease surveillance systems.”
“Disease outbreaks start and end at the community level, so focusing efforts there is critical. At the global health nonprofit where I work, Management Sciences for Health, we help local authorities develop preparedness plans so that leaders know how to react, communicate risks and lead residents in adopting preventive behaviors.” (C)

“In early May, a strange disease began to affect people in the southern Indian state of Kerala, killing 17 people. The cause was an almost unknown virus called Nipah virus. Even though the virus has been contained, for the moment, WHO is concerned about the Nipah virus which might indeed become the Disease X.
Many of the disease experts consider Nipah to be the most frightening and worrying ’emerging’ virus of the last decades, at least. It is no coincidence that WHO has it as one of the eight priority viruses for which a vaccine should be developed.
According to The New York Times, Nipah infection causes flu symptoms, such as fever, body aches, and vomiting, which often progress to acute respiratory syndrome and encephalitis, or brain inflammation.
Some survivors show persistent neurological effects, including personality changes.
WHO is concerned that Nipah virus might become the Disease X. (D)

“American researchers have developed a platform capable of delivering single-dose vaccines that fully protect against infectious diseases such as Zika, Ebola and Lassa fever…
The vaccines are suitable for repeated use, stable at refrigerator temperatures or lyophilized for non-cold chain needle-free application, and amenable to rapid and affordable scale-up for use in both epidemic response and routine vaccination, according to Basu.
In proof-of-concept studies, the researchers tested three independent vaccines against three different families of viruses. Each vaccine demonstrated full protection after a single dose, using various lethal challenge models. (E)

“The head of the World Health Organization (WHO) on Tuesday cautioned against declaring victory too early in Congo’s Ebola epidemic, despite encouraging signs that it may be brought under control.
“The outbreak is stabilizing, but still the outbreak is not over,” WHO chief Tedros Adhanom Ghebreyesus told journalists on a visit to Democratic Republic of Congo’s capital Kinshasa. “We are still at war, and we need to continue to strengthen our surveillance and … be very vigilant.” (F)

(A) The Next Plague Is Coming. Is America Ready?, by ED YONG , https://www.theatlantic.com/magazine/archive/2018/07/when-the-next-plague-hits/561734/
(B) Do we keep waiting for the next pandemic or try to prevent it?, by Seth Berkley https://www.statnews.com/2018/06/14/pandemic-prevention-ebola-drc-vaccines/?utm_source=STAT+Newsletters&utm_campaign=e1055e5b9f-MR_COPY_07&utm_medium=email&utm_term=0_8cab1d7961-e1055e5b9f-149527969
(C) Let’s not rely on vaccines, here’s how we can prepare for epidemics now, by MARIAN WENTWORTH, http://thehill.com/opinion/healthcare/391889-Lets-not-rely-on-vaccines-heres-how-we-can-prepare-for-epidemics-now
(D) WHO Is Concerned About Nipah Virus, As It Might Become The “Disease X”, by Joe Blair, https://www.healththoroughfare.com/disease/who-is-concerned-about-nipah-virus-as-it-might-become-the-disease-x/9110
(E) Platform developed for single-dose vaccines to treat viruses like Zika, Ebola, https://news.cgtn.com/news/3d3d674e3151444d78457a6333566d54/share.html
(F) ‘We are still at war’ with Ebola: WHO chief, https://www.srnnews.com/we-are-still-at-war-with-ebola-who-chief/
(G)

“Paul Jawor, who has just returned home from the African nation, admitted he was ‘very scared’ about the killer virus in a written account of his time on the ground…
Mr Jawor, a Doctors Without Borders and Médecins Sans Frontières water and sanitation expert, was sent to the DRC on May 20…
The current Ebola outbreak began in the poorly-connected region of Ikoko-Impenge and Bikoro – in the north east of the DRC.
It has since travelled 80 miles (130km) north to Mbandaka, a port city on the river Congo – an essential waterway – with around 1.2 million inhabitants.
Virologists fear there is a ‘major concern’ it will spread to Kinshasa – 364 miles (586km) south on the river, where 12 million people live.
The city, which is the capital of the DRC, has an international airport with regular flights to European cities Zurich, Frankfurt and Brussels.” (A)

Medical investigators will need to overcome the rural region’s extreme logistical hurdles to reconstruct transmission chains, vaccinate contacts and halt the spread…
Epidemiologists working in the remote forests have not yet identified the first case, nor many of the villagers who may have been exposed. Investigators will need to overcome extreme logistical hurdles to reconstruct how the virus was transmitted, vaccinate contacts and halt the spread.
“For an epidemic to be under control, you need a clear epidemiological picture,” said Dr. Henry Gray, the emergency coordinator for Doctors Without Borders.
“If you don’t know the stories of the people involved — who their families were, what their jobs were, where they went to weddings and funerals — then you don’t know the epidemic.”..
The W.H.O. is monitoring more than 900 contacts throughout Équateur province. As the vaccination program expands to the Bikoro and Iboko communities, where most cases have been reported, teams are relying on contact tracing to identify the most urgent recipients.
“This is where everything gets more complicated,” …The villages surrounding Bikoro and Iboko are among the most isolated and densely wooded pockets of Congo. Aid workers must use motorbikes to navigate cratered dirt roads that flood during the rainy season. Maps of some regions are incomplete, and vast gaps in cellular service thwart efforts to report data to central operations.
“Following the virus’s narrative may sounds easy to do on a suburban street outside Chicago,” said Dr. Salama. “But when you’re traveling hundreds of kilometers in a forest by motorbike to find each person, that’s very different epidemiological work.” …
Until investigators identify the index case, it is impossible to discern whether the first patient detected in April was truly the first human case or the hundredth, according to Dr. Gianfranco Rotigliano, the regional director of Unicef. Until then, it is impossible to quantify the crisis.
“These are the early days of the outbreak,” Dr. Salama said. “There can be lulls. We’ve seen that before. But there only needs to be one event — a super-spreader, like a funeral — to cause an explosion.”” (B)

“Globally, we must address three issues to tackle Ebola and other deadly pathogens. One is community engagement. Lack of trust between responders and communities has resulted in patients fleeing isolation, as well as likely missed cases and contacts. Ebola emerged in a remote community; it is essential to understand community perspectives and structure and to gain trust and enlist the community’s strengths to stop the disease.
Another issue is WHO’s effectiveness. The African Regional Office of WHO now has many staff with the needed technical and operational excellence, and the Geneva-based emergency program is more effective than before. But WHO country offices in DRC and elsewhere are not nearly as effective as they need to be. Tedros Adhanom Ghebreyesus, coming up on his first anniversary as WHO Director General, has unveiled a potentially transformative general program of work. His leadership will be essential for these ambitious goals and inspiring rhetoric to overcome operational and managerial weaknesses at WHO headquarters in Geneva, as well as in some regional and many country offices.” (C)

“The Trump administration has walked back its proposal to reclaim $252 million in unspent Ebola funds on Tuesday, which experts lauded as a welcome shift in the administration’s approach to global health leadership ― especially amid the new Ebola outbreak…
When President Donald Trump moved to cut the money the same week the current Ebola outbreak was announced in the Democratic Republic of the Congo, the public outcry from global health experts and Congress was swift. They argued that Trump was undermining the U.S. leadership role in world health issues.
Their concerns were compounded by the early May departure of Rear Adm. Tim Ziemer, formerly the National Security Council’s head of global health security; the breakup of his team into other divisions; and the April departure of White House homeland security adviser Tom Bossert, another champion of global health investment.
As Ronald Klain, the former Ebola czar under President Barack Obama, told HuffPost at the time: “Proposing a rescission of Ebola contingency funds on the very day that a new Ebola outbreak is announced is badly misguided; forcing out the two top officials in charge of epidemic response at the White House ― Tom Bossert and Tim Ziemer ― is even worse. Doing it all at the same time shows a reckless disregard for the dangers we face.””
Also disquieting was the fact that the U.S. waited a full two weeks after the first announcement of U.K. funds for the latest Ebola outbreak to announce its own full contribution of $8 million from the U.S. Agency for International Development.” (D)

“Companies and other players involved in the development of experimental Ebola drugs are jockeying to have their products tested in the outbreak in the Democratic Republic of the Congo, part of a chaotic and politically charged effort to use them in the midst of a crisis….
Experts say the maneuvering for space in which to try vaccines and drugs brings to mind the frantic days of the West African Ebola outbreak, when there were so many research teams in the field that a free-for-all of experimental testing ensued. Most of the clinical trials produced little in the way of insight into what actually might work against Ebola.
There’s a “rush to evaluate [treatments] because the window of opportunity for evaluating these interventions is always going to be short,” said Ross Upshur, a physician and ethicist who was on the WHO panel…
“If we don’t use the opportunity to learn in this situation, we’ll never be able to know which is better than the other in terms of the drugs,” said Dr. Peter Salama, the WHO’s deputy director-general for emergency response…
“It’s not a simple effort to do this sort of trial in this kind of environment,” Salama said.” (E)

(A) Ebola outbreak in the Democratic Republic of Congo that is feared to have killed 27 people is a ‘race against time’, aid worker warns, by STEPHEN MATTHEWS, http://www.dailymail.co.uk/health/article-5821781/Ebola-outbreak-DRC-race-against-time-aid-worker-warns.html
(B) As Aid Workers Move to the Heart of Congo’s Ebola Outbreak, ‘Everything Gets More Complicated’, https://mobile.nytimes.com/2018/06/01/health/ebola-congo-outbreak.html?rref=collection%2Ftimestopic%2FEbola&action=click&contentCollection=timestopics&region=stream&module=stream_unit&version=latest&contentPlacement=1&pgtype=collection
(C) Still not ready for Ebola, http://science.sciencemag.org/content/360/6393/1049.full
(D) Trump Walks Back A Disastrous Ebola Funding Cut And Experts Sigh In Relief, by Lauren Weber, https://www.huffingtonpost.com/entry/trump-walks-back-ebola-funding-cut_us_5b183d68e4b0599bc6dffd4d
(E) Ebola outbreak opens way to chaotic jockeying to test experimental drugs, by HELEN BRANSWELL, https://www.statnews.com/2018/05/30/ebola-experimental-treatments/

March 13th
“The White House appeared to declare victory this week for an Obama-era initiative to stamp out disease outbreaks around the world even as it moved to scale back the program…,
But the United States is set to dramatically shrink its contributions to the initiative, a point that the report omitted. The Centers for Disease Control and Prevention is preparing to narrow epidemic work from 49 countries to 10, an agency spokeswoman said.
That has alarmed health policy experts.
“It’s not a matter of if — but when — there will be another Ebola or Zika, and right now, the world isn’t ready,” said Dr. Thomas R. Frieden, who led the C.D.C. during the West African Ebola outbreak. “Many life-threatening gaps have been identified, but most of them haven’t been closed.” “ (A)

“The response to the Zika virus is fairly typical of both our strengths and weaknesses in dealing with infectious diseases, especially when they emerge. Existing drugs against other viruses were identified as potential therapeutics for Zika, efforts to develop a vaccine are underway and nearing completion, and the concern about Zika spurred some needed and valuable research. Those are encouraging signs, but these efforts were somewhat slow to get started and preceded by the usual complacency. We tend to close the barn door only after most of the horses have escaped.” (B)

May 8th
“The Government of the Democratic Republic of the Congo declared a new outbreak of Ebola virus disease (EVD) in Bikoro in Equateur Province today (8 May). The outbreak declaration occurred after laboratory results confirmed two cases of EVD.
The Ministry of Health of Democratic of the Congo (DRC) informed WHO that two out of five samples collected from five patients tested positive for EVD at the Institut National de Recherche Biomédicale (INRB) in Kinshasa. More specimens are being collected for testing.
WHO is working closely with the Government of the DRC to rapidly scale up its operations and mobilize health partners using the model of a successful response to a similar EVD outbreak in 2017.
“Our top priority is to get to Bikoro to work alongside the Government of the Democratic Republic of the Congo and partners to reduce the loss of life and suffering related to this new Ebola virus disease outbreak,” said Dr Peter Salama, WHO Deputy Director-General, Emergency Preparedness and Response. “Working with partners and responding early and in a coordinated way will be vital to containing this deadly disease.” “ (C)

May 17th
“An Ebola outbreak in the Democratic Republic of Congo has spread to a major city — Mbandaka, with a population of about 1 million people — officials said.
The country’s health minister said authorities are intensifying work to identify those who have been in contact with suspected cases. Another concern is the disease could be spread through commerce, as the city is a major trade thoroughfare on the banks of the Congo River.” (D)

May 17th
National Institutes of Health officials assured lawmakers on Thursday that U.S. health experts are following concerns of an Ebola outbreak in Africa closely and said a number of medical countermeasures have already been deployed in response.
“Obviously given our prior experience, we are on very high alert,” said Anthony Fauci, M.D., head of the National Institute of Allergy and Infectious Diseases, in response to a question about how worried the U.S. should be about reports that Ebola had been found in an urban area of the Democratic Republic of Congo….
…at least one case is now in a more populated area, he said: “Even though there is only one case there, there’s a total now of 44 cases, even though only two have been confirmed. There are 20 that are probable and 20 that are suspicious. So there are probably many more cases.”…
“We are on high alert. We are always concerned when there is Ebola. But we right now have a number of countermeasures that we were able to develop to go in and hopefully block that,” he said. “Our expectations are always cautious. Our hopes are always that we will not have the kind of outbreak that we saw in West Africa.” (E)

May 18th
“Congo at ‘Very High’ Risk as Ebola Strikes Major City. WHO raises the public-health risk to ‘very high,’ as the deadly virus reaches a large port city
Aid organizations and the Congolese government rushed supplies and health experts Friday to a major city in the Democratic Republic of Congo, after the World Health Organization raised the public-health risk from the latest Ebola outbreak to “very high.”
Congo’s threat from the deadly disease was elevated from high by the WHO, who also upped the risk to neighboring nations to high from moderate. Very high is the second-highest risk level available, below serious.” (F)

May 18th
“What’s the worse-case Ebola outbreak?
Public health officials would say it’s when the virus is spreading in a crowded urban environment that’s a major transportation hub and has dilapidated, ill-equipped health care facilities.
Unfortunately, that’s what’s happening right now in the northwest of the Democratic Republic of the Congo…
That’s why the World Health Organization along with Congolese officials and other aid agencies are scrambling to try to contain this outbreak before it grows much larger…
Congolese health officials now say there have been 45 suspected cases reported in their country since April. And 25 people have died. Laboratory testing of patient blood samples, however, has been progressing slowly; 14 of the cases have been confirmed as Ebola.
Four thousand doses of an experimental Ebola vaccine — which has to be stored at minus 60 degrees Celsius — have shipped to the DRC. Plans are being developed to try to vaccinate hundreds if not thousands in areas near where Ebola cases have been found.
Doctors Without Borders is setting up isolation wards and Ebola treatment centers both near the epicenter of the outbreak and in the port city of Mbandaka.
The Red Cross is recruiting local volunteers to collect and safely bury the dead.
“We have now 20 volunteers trained on how to do these burials,” says Karsten Voigt, operations manager for the International Federation of the Red Cross in the Democratic Republic of the Congo.” (G)

May 18th
“The Ebola outbreak in Democratic Republic of Congo can be brought under control and is not an international public health emergency, experts advising the World Health Organization said on Friday.
Earlier in the day the WHO had said the first confirmation of Ebola in Mbandaka, a city of about 1.5 million people, had prompted it to declare a “very high” public health risk to the country and a “high” risk to the region.
But the WHO’s Emergency Committee of 11 experts said the rapid response had mitigated the risk from the outbreak, which was declared 10 days ago and has killed 25 people since early April.
“Interventions underway provide strong reason to believe that the outbreak can be brought under control,” the committee said in a statement.
They decided not to declare a “public health emergency of international concern” (PHEIC), a formal alert that puts governments on notice and helps mobilise resources and research.
However, committee chairman Robert Steffen said the “vigorous” outbreak response must continue.” (H)

May 19, 2018
“ Three new cases of the often lethal Ebola virus have been confirmed in a city of more than one million people, Congo’s health minister announced, as the spread of the hemorrhagic fever in an urban area raised alarm.
The statement late on Friday said the confirmed cases are in Mbandaka, a city where a single case was confirmed earlier in the week.
There are now 17 confirmed Ebola cases in this outbreak, including one death, plus 21 probable cases and five suspected ones…
While Congo has contained several Ebola outbreaks in the past, all of them were based in remote rural areas. The virus has twice made it to Congo’s capital of 10 million people, Kinshasa, in the past but was rapidly stopped.
Health officials are trying to track down more than 500 people who have been in contact with those feared infected, a task that became more urgent with the spread to Mbandaka, which lies on the Congo River, a busy traffic corridor, and is an hour’s flight from the capital.” (I)

May 19th
“The U.S. government is preparing its most direct response yet to the outbreak that appears to have begun in April, readying staffers from the Centers for Disease Control and Prevention (CDC) to deploy to multiple communities in the Democratic Republic of Congo…
The present outbreak has raised anew questions about WHO and its capacity to respond to deadly viral threats. In the wake of the West African outbreak ago, when the ill-prepared WHO endured withering criticism for its lackluster response to the initial round of cases, the agency has undergone a remarkable round of self-flagellation, reorganizing to prioritize emergency preparedness and response while cutting bureaucracy.” (J)

“Regular vaccines can be tested in a few different ways. In one approach, researchers can vaccinate people and then expose them to the pathogen that the vaccine targets. That was never an option for a virus as deadly as Ebola.
Another approach is the standard randomized clinical trial. Enroll a large number of volunteers who may encounter the pathogen in their day-to-day life, and randomly assign some to be vaccinated. If researchers see more illness in the people who didn’t get the vaccine, it is considered to offer protection.
But a standard randomized clinical trial doesn’t work when a pathogen circulates as rarely as Ebola does. In the 42 years since the first known Ebola outbreak, only about 31,000 people are known to have been infected — and most of those infections occurred in the West African outbreak of 2013-2016. Outbreaks have ranged over a terrain that spans thousands of miles from West Africa to Central Africa.
Researchers could vaccinate thousands of people and follow them for years without seeing any disease in either the vaccine recipients or the control group.
Even testing during an outbreak was traditionally thought to be impossible. But the West African outbreak changed that thinking.
The vaccine now being fielded in the DRC — the VSV vaccine — was shown to be effective in Guinea in a so-called ring vaccination trial, in which people exposed to a case were vaccinated in an attempt to build a wall of immunity that cuts off the virus’s ability to spread.
In the latest outbreak, if the vaccine works as well as earlier studies suggest, it could present a paradigm shift in the way the world thinks about Ebola outbreaks.” (K)

May 24th
Two infected patients who fled from an Ebola treatment center in a Congo city of 1.2 million people later died, an aid group said Wednesday while asserting that “forced hospitalization is not the solution to this epidemic.”
As the number of suspected Ebola cases continued to rise, experts emphasized that more community engagement is needed to prevent the spread of the deadly virus.
Three patients left of their own accord from the isolation zone of the Wangata hospital in Mbandaka city between Sunday and Tuesday, said Henry Gray, emergency coordinator for Medecins Sans Frontieres.
One patient had been about to be discharged, he said. “The two others were helped to leave the hospital by their families in the middle of the night on Monday. One of the men died at home and his body was brought back to the hospital for safe burial with the help of the MSF teams; the other was brought back to the hospital yesterday morning and he died during the night,” Gray said in a statement.” (L)

May 24th
“Congo’s fight to rein in a deadly Ebola outbreak has authorities crossing the border to buy up available thermometers, a World Health Organization official said, as the health ministry on Thursday announced that confirmed cases had reached 30, including eight deaths.
The spread of the often lethal hemorrhagic fever to a provincial capital of 1.2 million people has health officials scrambling to monitor for Ebola at busy ports in the capital, Kinshasa, which is downstream from the infected city of Mbandaka on the Congo River…
In Kinshasa, travelers streamed off boats at ports on the Congo River and ran a gauntlet of health officials watching for signs of infection.
“We want to ensure that ports and airports are effectively protected,” WHO’s Congo representative Allarangar Yakouide told The Associated Press. “I assure you, we have already taken all the thermometers that are in Kinshasa, practically all the thermometers, and there are even colleagues who are going on the other side to Brazzaville to buy thermometers.”
The Republic of Congo’s capital is across the river from Kinshasa, a city of 10 million.” (M)

““A lot of what’s working now is the result of remembering and learning from previous failures,” said Jeremy Konyndyk, a senior policy fellow at the Center for Global Development and the director of foreign disaster assistance at the United States Agency for International Development during the Obama administration.
The Trump White House, however, appears to be uniquely amnesiac. On the same day that officials in the Democratic Republic of Congo reported the new Ebola cases, the administration sought to rescind $252 million in Ebola response funds left over from the earlier epidemic.
Before Congress acts on that request, members should recall how those funds came to be. Public health officials confirmed the 2014 outbreak at the end of a fiscal year, when most agency budgets — at the Centers for Disease Control and Prevention, U.S.A.I.D. and elsewhere — were tapped out. The search for additional funding delayed the American response, which in turn led to more lives lost and, ultimately, more money spent. To prevent the same thing from happening next time, the White House Office of Management and Budget agreed to leave these funds in U.S.A.I.D.’s budget so they would be on hand to combat the next emergency. Rescinding that money brings us back to where we started — ill prepared to mount a rapid response to a new infectious disease threat.
Around the same time that the administration proposed rescinding the funds, the National Security Council dissolved its biosecurity directorate, a small team focused exclusively on global health security threats and led by a director often referred to as the Ebola czar…
The Trump administration has also failed to seek renewed funding from Congress for a global health security initiative begun after the 2014 epidemic…
But whether and how these policy shifts will affect the current Ebola response remains to be seen. Though the outbreak seems to have been quickly contained, it involves a disease that we have fresh and terrifying experience with, in a country that has seen this particular foe nine times in living memory. The next outbreak may not offer such a head start. And when it comes, Mr. Trump’s shortsightedness, if it is not corrected, will have left us far less prepared.” (N)

(A) White House Hails Success of Disease-Fighting Program, and Plans Deep Cuts, by Emily Baumgaertner, https://www.nytimes.com/2018/03/13/us/politics/trump-ebola-disease-cuts-global-health-security-agenda.html
(B) Cannot be complacent, by Stephen S. Morse, https://www.theweek.in/health/more/2018/05/05/cannot-be-complacent.html
(C) New Ebola outbreak declared in Democratic Republic of the Congo, http://www.who.int/news-room/detail/08-05-2018-new-ebola-outbreak-declared-in-democratic-republic-of-the-congo#.WvMD0bhGhfE.email
(D) WHO mulling health emergency over Congo Ebola outbreak, by Susan McFarland, https://www.upi.com/Top_News/World-News/2018/05/17/WHO-mulling-health-emergency-over-Congo-Ebola-outbreak/1061526551624/
(E) NIH officials on ‘high alert,’ deploying countermeasures in response to Ebola outbreak, https://www.fiercehealthcare.com/hospitals-health-systems/nih-countermeasures-deployed-hopes-not-to-see-repeat-ebola-outbreak?
(F) Congo at ‘Very High’ Risk as Ebola Strikes Major City, by Nicholas Bariyo, https://www.wsj.com/articles/congo-at-very-high-risk-as-ebola-strikes-major-city-1526640110
(G) Ebola Outbreak: How Worried Should We Be?, by Jason Beaubien, https://www.npr.org/sections/goatsandsoda/2018/05/18/612010495/ebola-outbreak-how-worried-should-we-be
(H) Congo’s Ebola not an international emergency, can be controlled –WHO, by Tom Miles and Fiston Mahamba, https://www.reuters.com/article/us-health-ebola/ebola-congo-outbreak-high-risk-but-can-be-brought-under-control-who-idUSKCN1IJ0CM
(I) Congo says 3 new Ebola cases confirmed in large city,https://www.srnnews.com/congo-says-3-new-ebola-cases-confirmed-in-large-city/
(J) The Ebola superhighway: Why the new outbreak terrifies public health authorities, by Reid Wilson, http://thehill.com/policy/healthcare/388401-the-ebola-superhighway-why-a-new-outbreak-terrifies-public-health
(K) ‘You’re holding your breath’: Scientists who toiled for years on an Ebola vaccine see the first one put to the test, by HELEN BRANSWELL, https://www.statnews.com/2018/05/22/ebola-scientists-outbreak/
(L) Ebola response on ‘knife’s edge’ as timing key, WHO says, https://abcnews.go.com/Health/wireStory/nations-mobilize-prevent-ebola-spread-55374170
(M) Congo says confirmed Ebola cases have reached 30; 8 deaths; by Saleh Mwanamilongo, https://www.washingtonpost.com/world/africa/congo-says-ebola-cases-have-reached-30-warns-against-rumors/2018/05/24/88404b66-5f32-11e8-b656-236c6214ef01_story.html?noredirect=on&utm_term=.cbc0505f0c13
(N) Ebola, Amnesia and Donald Trump, https://www.nytimes.com/2018/05/22/opinion/ebola-outbreak-trump.html

May 3rd
“we are not finished with Zika… It very well could come back.” Are we ready?
highlight and click on

_____________
CURATED CHRONOLOGY OF 2016/ 2017 ZIKA CONUNDRUM & 2018 FLU EPIDEMIC

June 6, 2016
Former hospital prez says: Designate local Zika centers now. Medical experts do not know if, or where, or how much, or on what trajectory the Zika virus may spread across the United States.

August 13, 2016
The ER clerk asked me “How do you spell Zika?

August 19, 2016
With little gudiance about caring for Zika patients, hospitals are planning on their own

September 7, 2016
Hospitals are developing their own Zika preparedness models. Compare the Central Florida and Johns Hopkins approaches! Which template makes more sense?

September 29, 2016
All pregnant women with Zika diagnosed at community hospitals must be referred to academic medical centers for prenatal care!

May 15, 2017
EBOLA is back in Africa. Is ZIKA next? Are we prepared?

June 10, 2017
Study Findings: Five percent of pregnant women with a confirmed Zika infection.. went on to have a baby with a related birth defect

June 21, 2017
When I was a kid the only thing as scary as the polio epidemic was practicing getting under our desks for a nuclear attack…
https://doctordidyouwashyourhands.com/2017/06/when-i-was-a-kid-the-only-thing-as-scary-as-the-polio-epidemic-was-practicing-getting-under-our-desks-for-a-nuclear-attack/

July 18, 2017
In June WEST NILE was identified nationwide. Today it’s POWASSAN VIRUS. – ARE WE PREPARED FOR A SURGE OF EMERGING MOSQUITO AND TICK BORNE VIRUSES?

July 20, 2017
“Houston Braces for Another Brush With the Peril of Zika” *. But they are doing passive not active surveillance. IS YOU AREA’S HEALTH CARE SYSTEM PREPARED FOR A SURGE OF AN EMERGING VIRUS LIKE ZIKA?

July 27, 2017
Locally transmitted ZIKA case in Texas! Are we ready?

October 11, 2017
CDC deactivated its emergency response center for Zika.. The first probable locally acquired Zika case in 2017 has been confirmed in Texas….

November 7, 2017
a hand held device (was used) to measure the germ-count on some of New York City’s dirtiest surfaces
https://doctordidyouwashyourhands.com/2017/11/the-second-most-disgusting-germ-count-surface-turned-out-to-be-starbucks-door-handles/

January 8, 2018
“We are arguably as vulnerable—or more vulnerable—to another (flu) pandemic as we were in 1918.”

January 11, 2018
In the ICU at Massachusetts General Hospital, nurses use Gatorade to combat flu-related dehydration (due to shortages of intravenous fluids)

January 15, 2018
The CDC postponed its briefing on preparation for nuclear war and will focus on responding to severe influenza

January 17, 2018
“Think hospitals are under a strain now, from a slightly bad flu season? Wait until a really bad one hits.”

January 20, 2018
Government Shutdown. “The CDC would furlough key staff amid one of the most severe flu seasons in recent memory….”

January 23, 2018
“..in a severe (flu) pandemic, the U.S. healthcare system could be overwhelmed in just weeks.

updated May 24th

In 2014, I suggested several anchor principles for Ebola preparedness in New Jersey, as hospitals of all sizes and scope “marketed” their Ebola readiness, only to learn that it took well over 20/ 25 full time staff to care for one Ebola patient (and 50 in Dallas!).
These recommendations included that every hospital that certified its Emergency Room as ready for Ebola be subject to at least three separate drills using a standardized form, and then be subject to random “secret shopper” inspections; that anyone with a confirmed or suspected Ebola diagnosis be immediately transferred to a regional center hospital designated by national standardized criteria which could demonstrate that it has sufficient nursing staff “volunteers” to care for a least five patients round the clock; and that isolation hospitals be readied for instant activation, whether a closed hospital prepared for Ebola now and standing by, or a “virtual” hospital ready-to-go in military fashion.
Also there was a need to minimize Ebola patients walking into an ER unannounced, and suggested a statewide 800 number be established so patients can call ahead and be transported by a prepared ambulance team and taken to a regional center.
The Federal government, later than sooner, did exclusively designate three national bio containment facilities hospitals as Ebola Centers.
In 2016 I suggested that similar organizing principles were urgently need to be established for tiered Zika hospital preparedness by designating Zika Regional Referral Centers. More specifically:
1. There should not be an automatic default to just designating Ebola Centers as ZRRCs, although there is likely to be significant overlap.
2. Zika Centers should be academic medical centers with respected, comprehensive infectious disease diagnostic/ treatment and research capabilities, and rigorous infection control programs. They should also offer robust, comprehensive perinatology, neonatology, and pediatric neurology services, with the most sophisticated imaging capabilities (and Zika-related “reading” expertise).
3. National leadership in clinical trials.
4. A track record of successful, large scale clinical Rapid Response.
5. Organizational wherewithal to address intensive resource absorption.
6. Start preliminary planning for Zika care out of the initial designated ZRRCs.
Zika protocols will be templates for are other mosquito borne diseases lurking on the horizon, such as Chikungunya, MERS, and Dengue.

Where are we today on readiness for Zika or other emerging viruses?

“Farewell, carefree days of summer. The number of people getting diseases transmitted by mosquito, tick and flea bites has more than tripled in the United States in recent years, federal health officials reported on Tuesday. Since 2004, at least nine such diseases have been discovered or newly introduced here…
New tickborne diseases like Heartland virus are showing up in the continental United States, even as cases of Lyme disease and other established infections are growing. On island territories like Puerto Rico, the threat is mosquitoes carrying viruses like dengue and Zika…
Between 2004 and 2016, about 643,000 cases of 16 insect-borne illnesses were reported to the C.D.C. — 27,000 a year in 2004, rising to 96,000 by 2016. (The year 2004 was chosen as a baseline because the agency began requiring more detailed reporting then.).. (A)

Mosquito-borne disease epidemics happen more frequently.
Chikungunya and Zika viruses caused outbreaks in the US for the first time.
Seven new tickborne germs can infect people in the US…
The US is not fully prepared
Local and state health departments and vector control organizations face increasing demands to respond to these threats.
More than 80% of vector control organizations report needing improvement in 1 or more of 5 core competencies, such as testing for pesticide resistance.
More proven and publicly accepted mosquito and tick control methods are needed to prevent and control these diseases.” (B)

““Mosquitoes—and the viruses that they carry—are pushing up the incidence of malaria globally and causing periodic explosive outbreaks of Rift Valley fever, which first brings on flulike symptoms but can turn into a severe hemorrhagic fever akin to Ebola. Bluetongue virus, a ruminant virus spread by midges that was once confined to tropical areas, has reached as far as Norway. Studies have shown shifts in cholera transmission with recent climate variability. As emerging diseases migrate to new areas, they encounter new species, making outbreaks even more difficult to manage.
Unfortunately, writes journalist Lois Parshley in her feature article “Catching Fever,” the common enabler for the movement of each of these ailments is human-caused climate change. As weather patterns wreak more havoc, a Pandora’s box of microbes enters new terrain, stressing global public health systems…
Such alterations are happening whether we want to use the words “climate change” or not. Whether we acknowledge the scientific consensus, demonstrated in thousands of studies over decades, climate change is both real and promoted by human activities. Coastal communities are being affected by rising seas, drought-prone areas are arid for longer periods and, as our report shows, infectious agents are taking advantage of these more extreme weather patterns.” (C)

“Texas Department of State Health Services released a report its first two travel related Zika cases in Williamson County this Spring.
DSHS said it serves as a reminder for people to be cautious as they travel this summer.
Austin Public Health got a jump start on mosquito prevention with a tire drive Sunday afternoon. Dozens of people dropped of extra and abandon tires that tend to lay idle and collect water.
Ashley Hawes, APH Research Analyst said when the department surveys communities who attract mosquitoes they realized many had standing water collected by tires, bird baths, and rain gutters.
“If we can educate people of simple ways they can get rid of water in their area they can help reduce mosquitos and hopefully reduce the amount of people who get sick from diseases like West Nile and Zika,” Hawes said…
Hawes said one spoon full of water can attract about 10,000 mosquitoes “ (D)

“Two years ago, the world was gripped in Zika panic as the mosquito-borne virus infected millions and spread across 80 countries. Officials declared a global health emergency and tourists canceled their tropical vacations. Thousands of babies were born with devastating birth defects after their mothers were infected in pregnancy…
Still, “we are not finished with Zika,” said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. “Even though when you look at the number of infections, it’s dramatically down, it doesn’t mean they’re going to stay down,” Fauci said. “You’ve got to be careful when dealing with vector-borne diseases. They have a tendency to cycle in and out. It very well could come back.”…
The U.S. Centers for Disease Control and Prevention recently deactivated its emergency response system for Zika that was launched in January 2016…
The future of Zika could look like the pattern of mosquito-borne West Nile virus, which hit highs 9,862 cases in the U.S. in 2003 and hasn’t reached those numbers since. Or it could be more like dengue virus, with four subtypes that reliably infect more than 1 million people each year in the Southern Hemisphere…
“We can’t totally write it off yet,” Lawrence said. “It’s still a potential problem for people traveling. There is always the potential for changes in the virus. I don’t think the story is over.” “ (E)

“Despite the powerful technologies that scientists currently have to characterize pathogens and treat the infections they cause, the course and consequences of epidemics are still a source of surprise. Modern tools of molecular biology have enabled researchers to tear apart the Zika virus and decipher all of its genes and proteins, to map the antibodies and blood cells it mobilizes in infected individuals. But we still don’t know why some people contract the microbe with little or no illness, at most mild fever and muscle aches, while others suffer Guillain-Barré syndrome, a life-threatening paralysis. And we can’t distinguish between those pregnant women whose babies will be born deformed and others who seem to escape the most devastating neurological effects of the virus…
While the spectre of Zika in the Americas is fading, it’s wise to stay vigilant. Some experts worry that new cases of Zika recently reported in northern Mexico could presage another outbreak, with subsequent spread to U.S. border states. Relying on herd immunity is shortsighted, since over time fewer people will be infected and the virus can gain a new foothold. Indeed, the geographic distribution of Aedes aegypti, the mosquito species that transmits Zika, is expanding. The insect is infesting unexpected parts of North America and Europe; a population of A. aegypti was recently found in Washington, D.C., and appears to have survived four consecutive winters. The steady creep of climate change could bring A. aegypti farther north, where there is no herd immunity.” (F)

“An international consortium of researchers has reported that an Ebola vaccine appears to provide volunteers protection against the virus two years after they were injected — encouraging findings both for the public health community and the vaccine’s manufacturer.
An earlier study, conducted in Guinea near the end of the devastating West African Ebola outbreak, showed the vaccine from Merck, which is given in a single shot, rapidly generated protection against the virus. But how long that protection lasts remained an open question.
A fast-acting, long-lasting vaccine given in a single dose would be an effective tool for controlling dangerous Ebola outbreaks. Vaccinating health care workers, for instance, could prevent the type of spread within hospitals that, in the early days of an outbreak, can turn a smoldering outbreak into a conflagration.” (G)

“Analyses of more than 400 mice in New York City found that they carried previously unknown viruses and antibiotic-resistant bacteria.
Mice that live in the basements of New York City apartment buildings — even at the most exclusive addresses — carry disease-causing bacteria, antibiotic-resistant bugs and viruses that have never been seen before, a new study from Columbia University finds…
The viruses included nine species that had never been seen before and others that have not been known to cause human disease, according to the study, published Tuesday in the journal mBio.
But in a second study focused on bacteria, the researchers detected some of the most recognizable disease-causing pathogens, including Shigella, Salmonella, Clostridium difficile and E. coli. The scientists also found antibiotic-resistant bacteria like those that have become nearly untreatable at area hospitals…
“They are a potential source of human infection,” said Dr. W. Ian Lipkin, the epidemiologist at the Mailman School of Public Health at Columbia who was the senior author on the study. “The real message is that these things are everywhere.”” (H)

“A baby believed to have contracted a drug-resistant strain of typhoid, hospitalized in Hyderabad, Pakistan in February. Nadeem Khawer/European Pressphoto Agency
The first known epidemic of extensively drug-resistant typhoid is spreading through Pakistan, infecting at least 850 people in 14 districts since 2016, according to the National Institute of Health Islamabad.
The typhoid strain, resistant to five types of antibiotics, is expected to disseminate globally, replacing weaker strains where they are endemic. Experts have identified only one remaining oral antibiotic — azithromycin — to combat it; one more genetic mutation could make typhoid untreatable in some areas.
Researchers consider the epidemic an international clarion call for comprehensive prevention efforts. If vaccination campaigns and modern sanitation systems don’t outpace the pathogen, they anticipate a return to the pre-antibiotic era when mortality rates soared.
“This isn’t just about typhoid,” said Dr. Rumina Hasan, a pathology professor at the Aga Khan University in Pakistan. “Antibiotic resistance is a threat to all of modern medicine — and the scary part is, we’re out of options.” “ (I)

“Members of a government ethics panel have renewed their criticisms of a controversial study in which volunteers are to be deliberately infected with the Zika virus.
In an article published this month in the journal Science, panel members called for the establishment of ethics committees to review the design of such human-challenge studies, which are sometimes used to test vaccines.
“There is no way to turn back time,” said Ms. Seema Shah, a bioethicist at the University of Washington who chaired the panel and is a co-author of the new paper.
“When you’re asking someone to take a risk that won’t benefit them but may benefit others in the future, you need to know two things — that proper protections are in place, and that it’s really going to move the needle.”
With funding from the National Institutes of Health, the investigators plan to inoculate participants with potential vaccines and then to inject them with small doses of the Zika virus to test the vaccines’ effectiveness. The N.I.H. has not yet decided whether the research will proceed.
The scientists leading the trial say it is necessary to prevent a future epidemic. But Ms. Shah and other bioethicists convened by the N.I.H. concluded in 2017 that the research had “insufficient value” to justify the risks.” (J)

“A public warning and call to action, the new book “Lyme: The First Epidemic of Climate Change,” by investigative journalist Mary Beth Pfeiffer, sheds light on a tick-borne disease that recently has emerged to infect hundreds of thousands of people in the United States each year…
“There’s a problem with how we manage Lyme disease,” Pfeiffer said in a recent phone interview. “People need to be aware that we have a long way to go before we get to the point where we can adequately diagnose and treat Lyme disease and other tick-borne diseases.”..
“[Lyme] has been in the environment for millions of years. That we know.” Pfeiffer said. “But it really exploded just as climate change was getting to the point where we were noticing differences in temperature, differences in snowfall, differences in the length of growing seasons and so forth.”
“I ultimately concluded that it was the first major epidemic to move about the planet as a result of climate change,” Pfeiffer said, well aware that some readers may disagree.” (K)

“The White House appeared to declare victory this week for an Obama-era initiative to stamp out disease outbreaks around the world even as it moved to scale back the program.
The National Security Council released a report on Monday trumpeting the achievements of the multinational Global Health Security Agenda, which helps low-income countries halt epidemics before they cross borders. The report “clearly shows how the investments made by taxpayers to improve global health security are paying dividends,” White House officials said in the announcement.
But the United States is set to dramatically shrink its contributions to the initiative, a point that the report omitted. The Centers for Disease Control and Prevention is preparing to narrow epidemic work from 49 countries to 10, an agency spokeswoman said.
That has alarmed health policy experts.
“It’s not a matter of if — but when — there will be another Ebola or Zika, and right now, the world isn’t ready,” said Dr. Thomas R. Frieden, who led the C.D.C. during the West African Ebola outbreak. “Many life-threatening gaps have been identified, but most of them haven’t been closed.” “ (L)

“The response to the Zika virus is fairly typical of both our strengths and weaknesses in dealing with infectious diseases, especially when they emerge. Existing drugs against other viruses were identified as potential therapeutics for Zika, efforts to develop a vaccine are underway and nearing completion, and the concern about Zika spurred some needed and valuable research. Those are encouraging signs, but these efforts were somewhat slow to get started and preceded by the usual complacency. We tend to close the barn door only after most of the horses have escaped.” (M)

(A) Tick and Mosquito Infections Spreading Rapidly, C.D.C. Finds, by DONALD G. McNEIL Jr., https://www.nytimes.com/2018/05/01/health/ticks-mosquitoes-diseases.html
(B) Illnesses on the rise, https://www.cdc.gov/vitalsigns/vector-borne/index.html
(C) Our Planet, Ourselves: How Climate Change Results in Emerging Diseases, by Mariette DiChristina, https://www.scientificamerican.com/article/our-planet-ourselves-how-climate-change-results-in-emerging-diseases/
(D) DSHS reports first 2018 Zika cases in Williamson County, by Natalie Martinez, http://www.fox7austin.com/news/local-news/dshs-reports-first-2018-zika-cases-in-williamson-county
(E) Zika retreats widely, but health experts remain concerned, by Blythe Bernhard, https://medicalxpress.com/news/2018-01-zika-retreats-widely-health-experts.html
(F) Is Zika Gone for Good?, by Jerome Groopman, https://www.newyorker.com/tech/elements/is-zika-gone-for-good
(G) In encouraging sign, Ebola vaccine appears to provide long-lasting protection, by HELEN BRANSWELL, https://www.statnews.com/2018/04/16/ebola-vaccine-lasting-protection/?utm_source=STAT+Newsletters&utm_campaign=189d05d6b0-MR&utm_medium=email&utm_term=0_8cab1d7961-189d05d6b0-149527969
(H) New York Mice Are Crawling With Dangerous Bacteria and Viruses, by KAREN WEINTRAUB, https://www.nytimes.com/2018/04/17/science/urban-mice-viruses-bacteria.html
(I) ‘We’re Out of Options’: Doctors Battle Drug-Resistant Typhoid Outbreak, by EMILY BAUMGAERTNER, https://www.nytimes.com/2018/04/13/health/drug-resistant-typhoid-epidemic.html
(J) Ethicists Call for More Scrutiny of ‘Human-Challenge’ Trials, by EMILY BAUMGAERTNER, https://www.nytimes.com/2018/04/20/health/zika-study-ethics.html
(K) Could Lyme disease be the first epidemic of climate change?, by By Aislinn Sarnacki, http://bangordailynews.com/2018/04/16/homestead/could-lyme-disease-be-the-first-epidemic-of-climate-change/
(L) White House Hails Success of Disease-Fighting Program, and Plans Deep Cuts, by EMILY BAUMGAERTNER, https://www.nytimes.com/2018/03/13/us/politics/trump-ebola-disease-cuts-global-health-security-agenda.html
(M) Cannot be complacent, by Stephen S. Morse, https://www.theweek.in/health/more/2018/05/05/cannot-be-complacent.html

CURATED CHRONOLOGY OF 2016/ 2017 ZIKA CONUNDRUM & 2018 FLU EPIDEMIC

June 6, 2016
Former hospital prez says: Designate local Zika centers now. Medical experts do not know if, or where, or how much, or on what trajectory the Zika virus may spread across the United States.

August 13, 2016
The ER clerk asked me “How do you spell Zika?

August 19, 2016
With little gudiance about caring for Zika patients, hospitals are planning on their own

September 7, 2016
Hospitals are developing their own Zika preparedness models. Compare the Central Florida and Johns Hopkins approaches! Which template makes more sense?

September 29, 2016
All pregnant women with Zika diagnosed at community hospitals must be referred to academic medical centers for prenatal care!

May 15, 2017
EBOLA is back in Africa. Is ZIKA next? Are we prepared?

June 10, 2017
Study Findings: Five percent of pregnant women with a confirmed Zika infection.. went on to have a baby with a related birth defect

June 21, 2017
When I was a kid the only thing as scary as the polio epidemic was practicing getting under our desks for a nuclear attack…
https://doctordidyouwashyourhands.com/2017/06/when-i-was-a-kid-the-only-thing-as-scary-as-the-polio-epidemic-was-practicing-getting-under-our-desks-for-a-nuclear-attack/

July 18, 2017
In June WEST NILE was identified nationwide. Today it’s POWASSAN VIRUS. – ARE WE PREPARED FOR A SURGE OF EMERGING MOSQUITO AND TICK BORNE VIRUSES?

July 20, 2017
“Houston Braces for Another Brush With the Peril of Zika” *. But they are doing passive not active surveillance. IS YOU AREA’S HEALTH CARE SYSTEM PREPARED FOR A SURGE OF AN EMERGING VIRUS LIKE ZIKA?

July 27, 2017
Locally transmitted ZIKA case in Texas! Are we ready?

October 11, 2017
CDC deactivated its emergency response center for Zika.. The first probable locally acquired Zika case in 2017 has been confirmed in Texas….

November 7, 2017
a hand held device (was used) to measure the germ-count on some of New York City’s dirtiest surfaces
https://doctordidyouwashyourhands.com/2017/11/the-second-most-disgusting-germ-count-surface-turned-out-to-be-starbucks-door-handles/

January 8, 2018
“We are arguably as vulnerable—or more vulnerable—to another (flu) pandemic as we were in 1918.”

January 11, 2018
In the ICU at Massachusetts General Hospital, nurses use Gatorade to combat flu-related dehydration (due to shortages of intravenous fluids)

January 15, 2018
The CDC postponed its briefing on preparation for nuclear war and will focus on responding to severe influenza

January 17, 2018
“Think hospitals are under a strain now, from a slightly bad flu season? Wait until a really bad one hits.”

January 20, 2018
Government Shutdown. “The CDC would furlough key staff amid one of the most severe flu seasons in recent memory….”

January 23, 2018
“..in a severe (flu) pandemic, the U.S. healthcare system could be overwhelmed in just weeks.